Progressive Dental Kirkwood CORONA VIRUS SCREENING QUESTIONNAIRE PROGRESSIVE Name* First Last Date Of Birth* MM DD YYYY Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*YESNOAre you/they having shortness of breath or other difficulties breathing?*YESNODo you/they have a cough?*YESNOAny other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*YESNOYou selected YES, Please provide more details*Have you/they experienced recent loss of taste or smell?*YESNOAre you/they in contact with any confirmed COVID-19 positive patients?*YESNO Patients who are well but who have a sick family member at home with COVID-19 should consider postponing/rescheduling treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with dental treatment.NA*NA I agree to above mentioned consent.Signature of Patient or Legal Guardian*Today's Date: 05/22/2022UsernameThis is a hidden field Consent TextNAHideAgeThis is a hidden field