COVID-19 Screening Questionnaire

Remember

Mask wearing is suggested when entering office

Patient Information

First name

Last name

Email address

Phone number

Appointment Information

You must complete this COVID-19 screening questionnaire before each visit to our office on the day before your visit. Please confirm today's date and the date of your appointment.

Today's date

Date of your appointment

Q1. Immune/Risk status

Are you immunocompromised and/or live in a high-risk congregate care setting?

Yes No

Q2. Symptom History

Do you have any of the following symptoms that are new, worsening and not related to other known causes or conditions?

Fever or chills

Yes No

Runny nose/scratchy throat

Yes No

Headache

Yes No

New onset of cough or worsening of chronic cough

Yes No

Shortness of breath or difficulty breathing

Yes No

Muscle/body aches/extreme tiredness

Yes No

Decrease or loss of taste or smell

Yes No

New onset of nausea/vomiting/diarrhea

Yes No

Q3. Self Isolating

Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other government authority) that you should currently be quarantining, isolating or staying at home?

Yes No

Q4. Positive COVID-19 test

In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit?

Yes No

Please complete this questionnaire again if any of your answers change before your appointment.

NOTE: If you have had any changes to your overall health since your last appointment at our office, please contact the front desk

Remember that mask wearing is recommended when entering the office.

Your information will be encrypted.

COVID-19 Screening Questionnaire

Remember

Patient Information

Appointment Information

Q1. Immune/Risk status

Q2. Symptom History

Q3. Self Isolating

Q4. Positive COVID-19 test

NOTE: If you have had any changes to your overall health since your last appointment at our office, please contact the front desk

Remember

Boyce Dentistry Professional Corp