Northern Westchester Dental Care Covid-19 Screening Questionnaire Name* First Last Date Of Birth* Month Day Year Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?* YES NO Are you/they having shortness of breath or other difficulties breathing?* YES NO Do you/they have a cough?* YES NO Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?* YES NO Have you/they experienced recent loss of taste or smell?* YES NO Are you/they in contact with any confirmed COVID-19 positive patients?* YES NO Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)* YES NO You specified YES to one of the above questions, please provide more details.* Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.NA*NA I agree to above mentioned consent.Signature of Patient or Legal Guardian*Today's Date: 11/23/2025HiddenUsernameThis is a hidden field HiddenConsent TextNAHiddenHideAgeThis is a hidden field ← Fircrestkids → psqcovidscreening
