Alek Klebaner, DDS
501 Walnut Street
San Carlos, CA 94070
PH (650) 592-3436
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COVID-19
COVID-19 Patient Screening Form
Name:
Do you have a fever or above-normal temperature (>100.4°F)?
Select
Yes
No
Are you experiencing shortness of breath or having trouble breathing?
Select
Yes
No
Do you have a dry cough?
Select
Yes
No
Do you have a runny nose?
Select
Yes
No
Have you recently lost or had a reduction in your sense of smell or taste?
Select
Yes
No
Do you have a sore throat?
Select
Yes
No
Are you experiencing chills or repeated shaking with chills?
Select
Yes
No
Do you have unexplained muscle pain?
Select
Yes
No
Do you have a headache?
Select
Yes
No
Even if you don't currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
Select
Yes
No
Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?
Select
Yes
No
Have you been tested for COVID-19 in the last 14 days?
Select
Yes
No
What is the result of the testing?
Select
Positive
Negative
Unsure
Have you traveled more than 100 miles from your home in the last 14 days?
Select
Yes
No
I agree to notify the dental practice if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days.
Agree?
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