Covid-19 Form Questionnaire

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Welcome to our practice. To keep everyone safe, we are required to collect some information before you come in. Please take a minute to complete this form. After you are done, a team member will meet you at your car and bring you inside.

Covid Form questionnaire

Patient Name*
Email*
Mobile Number*
Color and model of car*
Have you tested positive for COVID-19 or awaiting the results?*
- Yes
- No
Do you have a fever?*
- Yes
- No
Do you have any shortness of breath?*
- Yes
- No
Do you have a dry cough?*
- Yes
- No
Do you have a runny nose?*
- Yes
- No
Do you have a sore throat?*
- Yes
- No
Do you have sneezing, watery eyes, and/or sinus pain/pressure that is unusual and not related to seasonal allergies?*
- Yes
- No
Have you experienced headaches, fatigue, or weakness?*
- Yes
- No
Have you lost your sense of taste and/or smell?*
- Yes
- No
Within the last 14 days, have you travelled to any foreign country?*
- Yes
- No
Within the last 14 days, have you travelled within the united states?*
- Yes
- No
If so, where?
Although exposure is unlikely, do you accept the risk and give consent to treatment?*
- Yes
- No
Name
Date
Date Format: MM slash DD slash YYYY
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Childers Orthodontics

201 West Washington
Benton, IL 62812

Phone: (618) 438-2815
Fax: (618) 551-3555

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