Corona Virus Screening Questionnaire Name* First Last Date of Birth* Do you/they have fever or you/they felt hot or feverish recently (14-21 days)*YesNoAre you/they having shortness of breath or difficulties breathing?*YesNoDo you/they have a cough?*YesNoAny other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*YesNoHave you /they experienced recent loss of taste or smell?*YesNoAre you/they in contact with any confirmed COVID-19 positive patients?*YesNoIs your/their age over 60?*YesNoDo you /they have Heart Disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?*YesNoHave you/they traveled in the past 14 days ?*YesNoPatients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before to proceeding with elective dental treatment.Signature of Patient or Legal Guardian*NameThis field is for validation purposes and should be left unchanged.