COVID-19 Questionnaire


All Questions Required

Do you have fever or have you felt hot or feverish recently (14-21 days)?

Are you having shortness of breath or other difficulties breathing?

Do you have a cough?

Do you have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Have you experienced recent loss of taste or smell?

Have you been 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.

Are you over 60 years old?

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Have you traveled in the past 14 days by commercial airline or bus?

5 + 1 =


665 E. Los Angeles Ave Ste. D Simi Valley, CA 93065


(805) 577-8333