COVID Screening Form in Garland, UT | Dustin V. Goodwin, DDS, PC

Have you had a fever >100.0º in the last 14 days?*

Yes
No

Have you had shortness of breath or difficulty breathing?*

Yes
No

Have you had a cough?*

Yes
No

Have you had any flu-like symptoms in the past 14 days? (nausea, vomitting, muscle aches, headach, fatigue)*

Yes
No

Have you been exposed to anyone with COVID-19 symptoms in the last 7-10 days?*

Yes
No

Have you recently lost taste or smell?*

Yes
No

Are you over the age of 60?*

Yes
No

Do you have any chronic medical conditions? (asthma, diabetes, heart conditions, auto-immune diseases, kidney problems, recent cancer treatments, etc.)*

Yes
No

Have you traveled outside of the state in the last 14 days?*

Yes
No

Positive responses to any of these questions might require us to reschedule your appointment.

For more information about COVID-19 (including testing sites), please see: https://health.utah.gov.

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