ADA COVID-19 Patient Screening Form

Please correct the errors described below.

First Name

Last Name

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

Yes No

Are you having shortness of breath or other difficulties breathing?

Yes No

Do you have a cough?

Yes No

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes No

Have you experienced recent loss of taste or smell?

Yes No

Are you 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.

Yes No

Are you over the age of 60?

Yes No

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

Yes No

Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

Yes No

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

For testing, see the list of State and Territorial Health Department Websites for your specific area's information.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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