Solihull Orthodontic Centre Pre-appointment Covid-19 Questionnaire This form MUST be completed for EVERY appointment and submitted by 8.30am on the day of your appointment. First Name (required) Last Name (required) Email (required) Please answer ALL questions below. Q1. Do you live with someone who is currently self isolating? Pre-Appointment YesNo Day of Appointment YesNo Q2. Have you been diagnosed with Coronavirus? Pre-Appointment YesNo Day of Appointment YesNo Q3. Are you having shortness of breath or other difficulties breathing? Pre-Appointment YesNo Day of Appointment YesNo Q4. Do you currently have a cough? or have you had a persistent dry cough in the last 14 days? Pre-Appointment YesNo Day of Appointment YesNo Q5. Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? Pre-Appointment YesNo Day of Appointment YesNo Q6. Have you experienced recent loss of taste or smell? Pre-Appointment YesNo Day of Appointment YesNo Q7. Are you in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. Pre-Appointment YesNo Day of Appointment YesNo Q8. Are you currently shielding? Pre-Appointment YesNo Day of Appointment YesNo Q9. Do you have heart disease, lung disease, kidney disease, diabetes or any autoimmune disorders? Pre-Appointment YesNo Day of Appointment YesNo Q10. Have you travelled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) Pre-Appointment YesNo Day of Appointment YesNo Q11. Have you been part of any mass gatherings or had close contact with many unacquainted people? Pre-Appointment YesNo Day of Appointment YesNo If you have a positive response to any of these questions please call the Practice on 0121 711 2727 well in advance of your scheduled appointment. Please check the box below before sending.
