Dr. Kinga Dentistry
Wellness Form
Name
(Required)
First
Last
Phone
Email
Do you have a cough?
(Required)
Yes
No
Do you have a fever now or have you in the past 14-21 days?
(Required)
Yes
No
Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?
(Required)
Yes
No
Are you experiencing shortness of breath or difficulty breathing?
(Required)
Yes
No
Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
(Required)
Yes
No
Have you experienced recent loss of taste or smell?
(Required)
Yes
No
Are you over the age of 60?
(Required)
Yes
No
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
(Required)
Yes
No
Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
(Required)
Yes
No
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