COVID-19 PATIENT SCREENING QUESTIONNAIRE

COVID-19 SCREENING QUESTIONNAIRE
In response to the recent Coronavirus (COVID -19) outbreak and the raised pandemic alert status by the World Health Organization (WHO), Children’s Dental Care is taking precautions to lessen the spread of the virus. All employees and independent contractors must have a screening form completed.

Please review the following self screening criteria:

Rows	Yes	No
Have you or anyone in the family (household) tested positive for COVID-19?	1	2
Have you or anyone in the family (household) been tested for COVID-19 and are waiting for results?	3	4
Do you or anyone in the family (household) have any of the following respiratory symptoms? Fever, Sore Throat, Cough, Shortness of Breath?	5	6
Have you or anyone in the family (household recently lost your sense of smell or taste?	7	8
Do you or anyone in the family (household) have any GI symptoms? Diarrhea? Nausea?	9	10
Even if you don’t currently have any of the above symptoms, have you or anyone in the family (household) experienced any of these symptoms in the last 14 days?	11	12
Have you or anyone in the family (household) been in contact with someone who has tested positive for COVID-19 in the last 14 days?	13	14
Have you or anyone in the family (household) traveled outside the United States by air or cruise ship in the past 14 days?	15	16
Have you or anyone in the family (household) traveled within the United States by air, bus or train within the past 14 days?	17	18

(If answered YES to any of the above questions, notify your supervisor and do not report to work. Contact your doctor for further advice.)
If you do not meet the criteria above, please sign below indicating that you have been provided with this information.
Employee Name:
First NameLast Name
Title
Signature:
Clear
Date:
MonthDayYear
Date
Temperature
Should be Empty: