Table 1.

Questionnaire of Oral Health Care Workers with COVID-19 in Wuhan.

Part 1. General information Name: Birthday: yyyy-mm-dd Address: Gender:   Name of medical institution: Occupation and department: Part 2. Clinical information 1. Onset of symptoms and time: yyyy-mm-dd □ Fever □ Cough □ Sputum production □ Hemoptysis □ Conjunctival congestion □ Fatigue □ Chest distress □ Sore throat □ Headache □ Myalgia □ Arthralgia □ Chills □ Diarrhea □ Nausea or vomiting □ Dyspnea □ Others 2. Time for confirmation: yyyy-mm-dd 3. Signs and symptoms (Please ✓): □ Fever □ Cough □ Sputum production □ Hemoptysis □ Conjunctival congestion □ Fatigue □ Chest distress □ Sore throat □ Headache □ Myalgia □ Arthralgia □ Chills □ Diarrhea □ Nausea or vomiting □ Dyspnea □ Others 4. Coexisting disorders (Please ✓): □ Hypertension □ Coronary heart disease □ Cerebrovascular diseases □ Diabetes □ Chronic pulmonary diseases □ Chronic renal diseases □ Chronic liver disease □ Immunodeficiency diseases □ Caner □ Other □ None 5. Hospitalization (Please ✓): □ Yes, yyyy-mm-dd □ No 6. Discharge (Please ✓): □ Yes, yyyy-mm-dd □ No 7. Relapse (Please ✓): □ Yes, yyyy-mm-dd □ No Part 3. Epidemiologic information 1. Contact history with confirmed or suspected cases of COVID-19 (Please ✓): □ Yes (If yes, please describe time of exposure and/or onset of symptom) □ Family member, yyyy-mm-dd (□ couple □ parent □ child □ other) □ Colleague, yyyy-mm-dd (□ in your department □ the other department) □ Patient, yyyy-mm-dd □ Other, specify: yyyy-mm-dd □ No 2. Whether working in fever clinic before onset of symptom? (Please ✓): □ Yes, yyyy-mm-dd □ No 3. Is there any confirmed or suspected case in your family or department? □ Yes (If yes, please describe time of exposure or onset of symptom) □ Family member, yyyy-mm-dd □ Colleague yyyy-mm-dd □ No 4. Select your prevention and control measures in the workplace (Please ✓): □ Disposable medical masks □ Caps □ Disposable gloves □ N95 or KN95 masks □ Facial shields □ Goggles □ Work clothes □ Gowns □ Protective clothes □ Hand hygiene □ Other □ None 5. Time off duty: yyyy-mm-dd