Mountain View Dental Associates Covid-19 Questionnaire

Name

Email Address

Have you been diagnosed with Covid-19? Have you been diagnosed with Covid-19? Yes No

Are you awaiting test results for Covid-19 lab investigations? Are you awaiting test results for Covid-19 lab investigations? Yes No

Have you been told by Public Health that you may have been exposed to Covid-19? Have you been told by Public Health that you may have been exposed to Covid-19? Yes No

Have you travelled outside of the Atlantic provinces in the past 14 days? Have you travelled outside of the Atlantic provinces in the past 14 days? Yes No

Symptoms of Covid-10 are similar for those of influenze or thoer respiratory illnesses. They can range from mild to severe. Have you recently experienced any of the following? Please check all that apply. Symptoms of Covid-10 are similar for those of influenze or thoer respiratory illnesses. They can range from mild to severe. Have you recently experienced any of the following? Please check all that apply. No symptoms Fever Dry cough Difficulty breathing Sore throat Runny nose Diarrhea Loss of taste Loss of smell