Covid 19 Screening Form | Elite Endodontics - Root Canal Treatment Essex

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Covid-19 Screening Questionnaire

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our staff and patients, we are conducting a simple screening questionnaire.

Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you.

If you prefer, we also have a printable version of this form.

Open PDF Version

Phone

Title *

First Name *

Middle Name

Last Name *

Date of Birth *

Home Address *

Home Address Line 2 *

Post Code *

Home Phone Number *

Work Phone Number

Mobile Phone Number *

Email Address *

Self-Declaration by Patient

Have you or have you been in contact with anyone who has been diagnosed with Coronavirus in the last 14 days? *

Yes No

Have you been in contact with anyone who has Self Isolated in the last 14 Days? *

Yes No

Have you experienced any cold or flu-like symptoms in the last 14 days including:

Do you have a new continuous cough? *

Yes No

Have you become breathless, or are you more breathless than usual? Do you struggle to breathe? *

Yes No

Have you experienced loss of taste and smell? *

Yes No

A sore throat, a tacky throat or soreness when swallowing food? *

Yes No

Do you have a high temperature (fever)? If you don’t have a thermometer do you feel hot to touch on your chest or back? *

Yes No

Are you feeling more confused than normal? *

Yes No

Are you too ill to do your usual daily activities? *

Yes No

Are you 70 OR OLDER with Cardiac Problems or Respiratory Problems or Diabetes? *

Yes No

Have you been advised that you need to be shielded? *

Yes No

I confirm that the information given in this form is true and accurate.

THANK YOU

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