COVID-19 Screening Form Patient Name First Last Date Date Format: MM slash DD slash YYYY Please answer the following:Do you have a fever or above normal temperature? Yes No Have you experienced shortness of breath or had trouble breathing? Yes No Do you have a dry cough? Yes No Do you have a runny nose? Yes No Have you recently lost or had a reduction in your sense of smell? Yes No Do you have a sore throat? Yes No Have you been in contact with someone who has tested positive for COVID-19? Yes No Have you tested positive for COVID-19? Yes No Have you been tested for COVID-19 and are awaiting results? Yes No Have you traveled outside the United States in the past 14 days? Yes No Where?Have you traveled within the United States in the past 14 days? Yes No Where?Do you have a weakened immune system? Yes No Are you currently undergoing treatment for cancer? Yes No Do you take steroids (Cortisone, Prednisone, Methylprednisolone) for any conditions? Yes No Do you have an autoimmune disease such as Lupus, rheumatoid arthritis, multiple sclerosis, psoriasis? Yes No Do you have diabetes? Yes No If yes, do you take insulin? Yes No Do you have asthma or COPPD? Yes No Signature Reach Us 3475 Plymouth Blvd. Suite 200 Plymouth, MN 55447 Phone: 763-694-6158 / Fax: 763-577-1375 info@epicperio.com Map / Directions Forms New Patient Letter Patient Registration Medical History Dental History Consent Form Navigation Home Dr. Barss Dr. Jensen Services & Info Dental Professionals
