Patient Screening Form

Patient Name

Date

Pre-Appointment

Initials:

1. Are you over the age of 60?

Yes No

Exposure Screening

2. In the last 14-days, did you have contact with someone who was diagnosed with COVID-19?

Yes No

3. In the last 14-days, did you live in or visit a place where COVID-19 is spreading?

Yes No

4. In the last 14-days, have you worked or volunteered in a hospital, emergency room, clinic, medical office, ambulance service, first responder service, or any health care setting or take care of patients as a student or part of your work?

Yes No

5. In the last 14-days, have you traveled to any regions affected by COVID-19?

Yes No

Check for Symptoms

6. Do you have a fever or have you felt hot or feverish in the last 2- days?

Yes No

7. Are you experiencing shortness of breath or difficulties breathing?

Yes No

8. Do you have a cough?

Yes No

9. Do you have a runny or stuffy nose?

Yes No

10. Do you have a sore throat?

Yes No

11. Do you have any muscle aches, body aches, or headaches?

Yes No

12. Are you experiencing fatigue or malaise

Yes No

13. Are you experiencing nausea, vomiting, or diarrhea?

Yes No

14. Are you experiencing gastrointestinal upset or changes?

Yes No

15. Have you experienced recent loss of taste or smell?

Yes No

Assess for High Risk Conditions

16. Do you have any preexisting medical conditions?

Yes No

In-Office Appointment

Initials

1. Are you over the age of 60?

Yes No

Exposure Screening

2. In the last 14-days, did you have contact with someone who was diagnosed with COVID-19?

Yes No

3. In the last 14-days, did you live in or visit a place where COVID-19 is spreading?

Yes No

5. In the last 14-days, have you traveled to any regions affected by COVID-19?

Yes No

Check for Symptoms

6. Do you have a fever or have you felt hot or feverish in the last 2- days?

Yes No

7. Are you experiencing shortness of breath or difficulties breathing?

Yes No

8. Do you have a cough?

Yes No

9. Do you have a runny or stuffy nose?

Yes No

10. Do you have a sore throat?

Yes No

11. Do you have any muscle aches, body aches, or headaches?

Yes No

12. Are you experiencing fatigue or malaise

Yes No

13. Are you experiencing nausea, vomiting, or diarrhea?

Yes No

14. Are you experiencing gastrointestinal upset or changes?

Yes No

15. Have you experienced recent loss of taste or smell?

Yes No

Assess for High Risk Conditions

16. Do you have any preexisting medical conditions?

Yes No

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

Dentist initials

1. Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

2. Malaise - A general feeling of discomfort, illness, or uneasiness whose exact cause are difficult to identify.

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.

Signature

Date

Examples of High-Risk Medical Conditions

Chronic Lung Disease

Asthma
COPD
Other chronic conditions associated with impaired lung function or that require home O2

Serious Heart Conditions

Congestive heart failure

Diabetes with Complications

Limb amputation
Kidney disease
Vision problems
Heart disease
History of stroke
Uncontrolled diabetes

Neurological Conditions that Weaken Ability to Cough

Disorders of the brain, spinal cord, peripheral nerve and muscle
Cerebral palsy
Epilepsy
Stroke
Intellectual disability
Mod-severe developmental delay
Muscular dystrophy
Spinal cord injury

People with Weakened Immune System

Seeing a doctor for cancer
Chemotherapy
Radiation treatment
Organ donation
Bone marrow transplant
Consuming high doses of oral steroids and /or immunosuppressant
HIV/AIDS

Dialysis

Under treatment for kidney disease
Receiving dialysis
Chronic kidney disease

Cirrhosis of the liver

Cirrhosis
Chronic hepatitis
Under treatment or has liver disease

Extreme Obesity

BMI greater than or equal to 40

Pregnancy

In the last 2-weeks
Currently

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