Dear Patient: in order to protect your health and your family’s health we are following the guidelines of the CDC and ADA and kindly request that you fill up this questionnaire two days prior to your appointment, and the day of your appointment. Name* First Last Date Date Format: MM slash DD slash YYYY Time Point*Please Selectpre-appointmentday-of-appointment Please answer the following questions.Do you/they have fever or have you/they felt hot or feverish recently (14-21- days)?*YesNoAre you/they having shortness of breath or other difficulties breathing?*YesNoDo you/they have a cough?*YesNoAny other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*YesNoHave you/they experienced recent loss of taste or smell?*YesNoAre you/they in contact with any confirmed COVID-19 positive patients?*YesNoPatients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.Is your/their age over 60?*YesNoDo you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders*YesNoHave you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)*YesNoThank you for your understanding, we look forward to seeing you soon, Dr. Grauer and Team.