ADA COVID-19 PATIENT SCREENING QUESTIONNAIRE

*Indicate Yes or No and provide relevant comments.

Yes No
Are you in contact with anyone who has been confirmed to be COVID-19 positive?
Have you travelled in the past 14 days to any regions affected by COVID-19?
Do you have a fever, or have you felt feverish recently?
Do you have a cough?
Are you over the age of 65?
Are you having shortness of breath or any difficulty breathing?
Do you have chills or repeated shaking with chills?
Do you have any muscle pain?
Do you have any recent onset of headache or sore throat?
Do you have any other flu-like symptoms?
Do you have any recent loss of taste or smell?
Have you experienced any recent GI upset or diarrhea?

When you click the Finish button, an email will be sent to you and the medical centre with a PDF of your consent.