COVID19 QUESTIONNAIRE

Firstly, we need to know who you are. We then need you to re-confirm your email and mobile number:

• Should you not have an email address please contact the clinic on

01273 202102

• immediately.

Now please carefully read the following and each and every question before answering:

• Have you been in communication with someone who may have COVID-19 (coronavirus) infection or had any of the following recently? Please tick all that apply. (required)

• I have been in contact but I am asymptomatic
• Persistent cough
• Shortness of breath or difficulty breathing
• Temperature above 37.8 degrees
• Any symptoms of respiratory tract illness whatsoever
• Loss of taste and / or smell
• Unexplained tiredness or lethargy
• Muscular aches
• I have not had any of the above
• If you have responded positively to any of these symptoms, we would strongly advise self isolating and delaying non-essential care for at least one month. If you have a dental emergency please contact the practice on hello@twentyonedental.co.uk so that we may make special arrangements for your emergency care.
  

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  Based on your activity over the last 4 weeks, how would you subjectively classify your risk of being exposed to or infected by COVID-19? (required)

• High risk – Frontline health care worker or confirmed case of infection at home
• Moderate risk – Key worker in contact with public but without symptoms or known exposure to an infected individual
• Low risk – Have been isolated / in lockdown alone or with family members with minimal social contact and no known exposure to an infected individual
• Previously infected and recovered – Confirmed by hospital testing with documentation (please bring documentation with you when attending)