COVID-19 Patient Questionnaire - Dental clinic Anja Siegl, dr. dent. med.

Do you have a fever (above 37.5º C)?
YesNo

Do you have a cold?
YesNo

Are you coughing?
YesNo

Do you have a sore throat?
YesNo

Do you have a changed taste or smell?
YesNo

Do you have a feeling of shortness of breath or pressure in your chest?
YesNo

Do you have muscle pain?
YesNo

Do you have digestive problems (diarrhea or vomiting)?
YesNo

Does anyone else have such problems at home or at work?
YesNo

Did you have a positive test on Covid-19?
YesNo

Have you been in contact with a COVID-19 confirmed patient (sick relatives, roommates)?
YesNo

I state that the above statements are true. If I find that the answer to any of the questions is * Yes *, I will immediately inform the Dental Clinic Anja Siegl and consult about the postponement of the appointment.