PreScreening Questions - Portland Smiles

Name*

First Last

Date*

Do you have fever or have you felt hot or feverish recently (14-21 days)?*

Are you having shortness of breath or other difficulties breathing?*

Do you have a cough?*

Any other flu-like symptoms, such as gastrointestional upset, headache or fatigue?*

Have you experienced recent loss of taste or smell?*

Are you in contact with any confirmed COVID-19 positive patients?*

Is your age over 60?*

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*

Have you traveled outside the state or to any infected areas in the past 14 days?*

Phone

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