Covid 19 Questions Patient Name/Paciente*Date/Fecha* Date Format: MM slash DD slash YYYY Email* As a safety measure to our staff and other patients, we kindly ask that you answer the following questions: Do you have fever or experience fever within the past 14 days?Have you experienced a recent onset of respiratory problems, such as a cough, sore throat, difficulty in breathing, or any muscle pain or gastrointestinal problems within the past 14 days?Have you had, within the past 14 days foreign travel?Have you had any contact within the past 14 days with anyone who has traveled to China, Hong Kong, Macau, South Korea, Italy or Iran?Have you come in contact with a patient with confirmed 2019-nCov infection within the past 14 days?Are there at least two people with documented experience of fever or respiratory problems within the last 14 days having close contact with you?Have you recently participated in any gathering, meetings, or had close contact with many unacquainted people?I will not hold Bliss Dental accountable/liable if I get sick.(please initials) Como medida de seguridad para nuestro personal y otros pacientes, le rogamos que responda las siguientes preguntas: ¿Tiene fiebre o ha tenido fiebre en los ultimos 14 dias?¿Ha experimentado una aparicion reciente de problemas respiratorios como tos, dolor de garganta, dificultad para respirar, dolor muscular o problemas gastrointestinales en los ultimos 14 dias?¿Ha viajado al extranjero en los ultimos 14 dias?¿Ha tenido algun contacto en los ultimos 14 dias con alguien que haya viajado a China, Hong Kong, Macao, Corea del Sur, Italia o Iran?¿Ha entrado en contacto con un paciente con infeccion confirmada de 2019-nCoV en los ultimos 14 dias?¿Hay al menos dos personas con experiencia documentada de fiebre o problemas respiratorios en los ultimos 14 dias que tengan contacto cercano con usted?¿Ha participado recientemente en alguna reunion , fiesta o ha tenido contacto cercano con muchas personas desconocidas?Bliss Dental no va a ser responsable si yo me enfermo. (iniciales) Gracias por su cooperacion. CommentsThis field is for validation purposes and should be left unchanged.
