Preevalutation Form - Clinica Orthodontia

Surname

First Name

Contact Number

Date of Birth

Age

Sex

Address

Country of Birth

Nationality

Occupation

RISK FACTOR QUESTIONNAIRE
Have you ever visited any other country prior to your planned visit to our clinic? If yes, input the specific country/ies or city/ies visited (from January 2020)

If yes, when did your arrive in the Philippines?

HISTORY OF 2019 NCOV EXPOSURE
Have you had close contact with persons with confirmed case of Covid-19?

Have you ever experienced any of the following respiratory symptoms prior to your visit to our clinic?

Onset of Symptoms

Others

Are you vaccinated?

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