COVID-19 Questionnaire | COVID-19 Questionnaire - Kazemi Oral Surgery

Vaccination Status:

Fully Vaccinated

Partially Vaccinated

Not Vaccinated

Have you had any cough, shortness of breath, other respiratory problems, or other symptoms associated with COVID-19 since January 2020? *

No

Yes

Have you had fever within the last 30 days? *

No

Yes

Have you been in contact with anyone suspected or with confirmed positive test to coronavirus? *

No

Yes

Have you been tested for Coronavirus? *

No

Yes: The results were negative

Yes: The results were positive

Have you traveled internationally within the last 30 days? *

No

Yes

Have you traveled to any states with recent increase in number of COVID-19 cases within the last two weeks? *

No

Yes

Have you been in any large gatherings including protests, religious events / programs, or social events within the last two weeks? *

No

Yes

How would you describe your personal discipline in social distancing and mask wearing habits?

Very disciplined

Somewhat disciplined

Mildly disciplined

Not disciplined

Have you had any recent changes in your health? *

No

Yes (describe below)

Describe any changes in your health

First Name *

Last Name *

Date *