COVID-19 Self Screening Questionnaire

You must answer “NO” to all the questions in this questionnaire in order to enter our physical location. If you answer “YES” to any of the questions, please refrain to enter the clinic building. If you experience any symptoms or answer “YES” to any of these questions, you must immediately contact your health care professional for recommended next steps.

1) Have you had any of the following symptoms in the last 24 hours? *
Yes No
Cough
Shortness of breath of difficulty breathing
OR at least TWO of the following symptoms in the last 24 hours: *
Yes No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

If you answered “Yes” to question one, please DO NOT visit clinic. You should: Self-quarantine for at least 10 days from the date on which you first experienced any of the above symptoms; AND Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND Improved respiratory symptoms (no cough, shortness of breath)

2) In the last 14 days have you: *
Yes No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise

If you answered “Yes” to any part of question two, please DO NOT visit the clinic. You should self quarantine for at least 14 days. I certify to the best of my knowledge; this information is accurate.

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Contact Us by Phone Number or Email Address

(226) 271-2004 / 1 (844) 510-5050 OR support@harmonydental.care

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