Covid-19 Questionnaire | Landayan Dental

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COVID-19 Assessment Questionnaire

Our team is taking precautionary measures to protect you!

Please answer this form truthfully as this will help prevent

the spread of COVID-19 Virus in our community.

Risk Factor Questionnaire

Have you ever visited any countries a month prior to your visit to our clinic?

If yes, specify country/ies or city/ies visited (from most recent) & when you arrived in the Philippines. If No, input NA.

History of 2019 NCoV Exposure

Have you had close contact with Persons with confirmed case of Covid-19?

Yes

Have you had close contact with Persons Under Investigation (PUI)?

Yes

Have you had close contact with Persons Under Monitoring (PUM)?

Yes

If yes, how many times (total)? If no, input NA.

If Yes, for how long each time?

Not applicable

< 5 minutes

5-15 minutes

> 15 minutes

Face to face exposure

Face to face exposure with personal protective equipment (PPE)

Indicate type of PPE

Please indicate if you are experiencing the following symptoms:

Sore Throat

Runny Nose

Cough

Shortness of breath

Chills

Nausea

Headaches

Muscle aches

Joint aches

General Malaise

Loss of appetite

None

Other symptoms not included in the list. Please specify.

I hereby declare all the above information provided above are accurate.

Thank you for submitting! Please give us time to assess.

The clinic's representative will be in contact with you prior to your scheduled visit. Should your answers to the above questions change in the interim, please advise ASAP.

THE GROVE

2F Retail Row, The Grove By Rockwell,

E.Rodriguez Jr., Pasig

OPENING HOURS

The Grove, Pasig Branch

Tuesday - Sunday: 10:00am – 7:00pm

8256-0791 | +63 977-6863662

BY APPOINTMENT ONLY

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