Dr. Roger Miya COVID-19 Screening Form
Please fill out this form before you come into the office. We will ask you the same questions once again on the day of your visit. If you are answering the questions for another patient, please answer the questions from their perspective. Please fill out a separate form for each patient.
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Email *
Patient's full name *
Do you have a fever or have you felt hot or feverish in the past 14-21 days? *
Are you having shortness of breath or other difficulties breathing? *
Do you have a cough? *
Do you have or have you had in the past 14-21 days any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *
Have you experienced recent loss of taste or smell? *
Are you in contact with any confirmed COVID-19 positive patients? (Patients who are well but who have a sick family member at home withCOVID-19 should consider postponing elective treatment.) *
Is your age over 60? *
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? *
Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) *
Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
For testing, see the list of State and Territorial Health Department Websites for your specific area’s information. https://www.cdc.gov/publichealthgateway/healthdirectories/healthdepartments.html
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