Monthly Archives: June 2020

Covid-19 Questionare

ANTHONY L. TORTORICH, D.D.S., P.A.
Diplomate, American Board of Oral and Maxillofacial Surgery
Diplomate, National Dental Board of Anesthesiology
4220 N. RODNEY PARHAM, SUITE 103
LITTLE ROCK, ARKANSAS 72212
office@tortorichoralsurgery.com
Telephone 501-224-8332

 

PATIENT COVID-19 QUESTIONARE

1. Have you had fever, cough, shortness of breath, or difficulty breathing? YES NO
2. Have you had chills or repeated shaking with chills? YES NO
3. Have you had muscle pain, headache, or sore throat? YES NO
4. Have you had new loss of smell or taste? YES NO
5. Have you returned from overseas travel or from states/metropolitan
areas considered hot spots for COVID-19 in the last 14 days? YES NO
6. Have you had contact with a person known to be infected with
COVID-19 within the last 14 days? YES NO
7. Do you have a compromised immune system? YES NO