Vargas-Pernia Dental Clinic

09/04/2021

28/06/2020

To our Dear Patients,

For us to be able to attend or schedule you regarding your dental concerns, KINDLY READ THOROUGHLY and answer this assessment questionnare of potential risk factors for 2019-Novel Corona Virus Infection HONESTLY.

Full Name:
Date of Birth:
Occupation:
Location of work:
Schedule of work:
Age:
Gender:
Civil Status:
Address:
Contact number:

1. Have you ever visited any countries a month prior to your visit to out health care facility?

•If yes, what country?

•If yes, when did you arrive in the philippines?

2.Have you had close contact with person confirmed of Covid-19?

3.Have you had close contact with person PUI/PUM of Covid-19?

4.Have you experienced any sore throat?

•Runny nose?

•Cough?

•Difficulty in breathing?

•Fever?

5.Any medical conditions that we should be aware of? Example: Diabetes, heart problem, cancer, etc.

6.Any current medications being taken? If yes, pls do note the name of meds.

7.Any known allergies to medicines?

8.When is the last day of going to public market or groceries?

Thank you for your cooperation!