COVID 19 Questionnaire for Dental Practices

Patient Name:

Date:

Please select only one answer. If you are confused, discuss it with your provider.

(1) Do you have fever or experience fever within the past 14 days?

YES NO

(2) Have you experienced a recent onset of respiratory problems, such as a cough or difficulty in breathing within the past 14 days?

YES NO

(3) Have you, within the past 14 days, traveled to Wuhan city and its surrounding areas, or visited the neighborhood with documented 2019-nCoV transmission?

YES NO

(4) Have you come into contact with a patient with confirmed 2019-nCoV infection within the past 14 days?

YES NO

(5) Have you come into contact with people who come from Wuhan city and its surrounding areas, or people from the neighborhood with recent documented fever or respiratory problems within the past 14 days?

YES NO

(6) Are there at least two people with documented experience of fever or respiratory problems within the last 14 days having close contact with you?

YES NO

(7) Have you recently participated in any gathering, meetings, or had close contact with many unacquainted people?

YES NO

If a patient replies "yes" to any of the screening questions, and his/her body temperature is below 37.3 C° (99.14 F), the dentist should defer the treatment until 14 days after the exposure event. The patient should be instructed to self-quarantine at home and report any fever experience or flu-like syndrome to the local health department.

If a patient replies "yes" to any of the screening questions, and his/her body temperature is 37.3 C° (99.14 F) or above, the patient should be immediately quarantined, and the dental professionals should report to the infection control department of the hospital or the local health department.

If a patient replies "no" to all the screening questions, and his/her body temperature is below 37.3 C° (99.14 F), the dentist can treat the patient with extra- protection measures, and avoid spatter or aerosol-generating procedures to the best of their ability.

If a patient replies "no" to all the screening questions, but his/her body temperature is more than 37.3 C° (99.14 F), the patient should be instructed to the fever clinics or special clinics for COVID-19 for further medical care.

Peng, X., Xu, Li, Y. et al. Transmission routes of 2019-nCov and controls in dental practice. Int J Oral Sci 12, 9 (2020). https://doi.org/10.1038/s41368-020-0075-9 Retrieved from https://www.nature.com/articles/s41368-020-0075-9#Fig1 March 16, 2020

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