Assessment Questionnaire - Teeth Hub Dental Clinic

Assessment Questionnaire of Potential Risk Factors for 2019-Novel Corona Virus Infection

Reminder: Bawal ang intensyonal na pagbibigay ng maling impormasyon tungkol sa COVID-19. Sa ilalim ng RA 11332 o Mandatory Reporting of Notifiable Diseases & Health Events of Public Health Concern Act kaugnay ng Presidential Proclamation 922, ito ay may parusang multa at pagkakakulong.

Informed Consent

1. I give my full consent to have dental treatment done to me or my child(ren) in this time of pandemic caused by COVID-19 disease.

2. I am aware that the virus can be transmitted by contact through surface and that it can be infective for 5 to 72 hours. I am aware that it is impossible to identify who is probable, suspect or COVID-19 positive. Because of this, treatment options are limited to urgent and emergent care to protect me, other patients and the dental staff.

3. I recognize that the clinic is adhering to the strictest infection control protocols for my protection and as such, I agree to cover the entails.

4. I fully understand the risk that because of the nature of the virus, by simply leaving my home, travelling to the clinic, the clinical procedures, and even by simply staying in the dental office, there is a chance of contracting the virus. Should I contact the virus, I hereby agree that I shall not hold the dental office liable.

5. I am also giving my consent that in accordance to the IATF rules, my identity shall be revealed for possible contact tracing for the interest and safety of the community.

For the good of the community, I am TRUTHFULLY answering the questionnaire and fully understand the informed consent form.

Honesty saves lives.

* Denotes required field
* Selecting I agree means giving full consent and is equivalent to patient’s signature.

I agree to the informed consent agreement.*

Surname*

First name*

Date of birth*

Age*

Sex*

Contact Number*

Civil Status*

Current Address*

Nationality*

Occupation*

Are you a student?*

Are you a health care personnel/frontliner (police, coast guard, soldier)?*

Risk Factor Questionnaire

Have you visited any country a month prior to your visit to our health care facility?*

If yes, when did you arrive in the Philippines?

If yes, specify the country/ies or city/ies visited (from most recent)?

Where did you go for the last 14 days? Where and when? (ex: mall, province, hospital, work)?

History of 2019 NCoV Exposure

Have you had close contact with persons with confirmed cases of COVID-19?*

Persons under investigation (PUI)?*

Persons under monitoring (PUM)?*

If yes, how many times?

If yes, for how long each time?

What type of PPE?

Have you had any COVID-19 test?

Date of last test:

Type of test:

Result of test:

Symptoms

Have you ever experienced any respiratory symptoms (sore throat, runny nose, cough, shortness of breath) prior to your visit to our health care facility?*

If no, please skip the following questions

Date of onset symptoms

Fever

If yes, specify maximum temperature

Please indicate if you are experiencing the following symptoms

Loss of taste

Loss of smell

Sore throat

Cough

Runny nose

Shortness of breath

Other symptoms

Chills

Nausea

Diarrhea

Headaches

Joint Aches

Muscle Aches

General Malaise

Loss of Appetite

Other symptoms not included on the list:

Are you vaccinated for COVID-19? (Kindly leave blank if N/A)

Brand of vaccine (Kindly leave blank if N/A)

First dose (Kindly leave blank if N/A)

Second dose (Kindly leave blank if N/A)

Booster shot - First dose (Kindly leave blank if N/A)

Booster shot - Second dose (Kindly leave blank if N/A)

Kindly attach your vaccination card if applicable

* Denotes required field

Assessment Questionnaire of Potential Risk Factors for 2019-Novel Corona Virus Infection

Risk Factor Questionnaire

History of 2019 NCoV Exposure

Have you had any COVID-19 test?

Symptoms

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