Patient Screening Form

Patient's Name

PRE-APPOINTMENT

IN-OFFICE

Date

1. Do you /they have fever or have you/they felt hot or feverish recently?

Yes No

1. Do you /they have fever or have you/they felt hot or feverish recently?

Yes No

2. Are you/they having shortness of breath or other difficulties breathing?

Yes No

2. Are you/they having shortness of breath or other difficulties breathing?

Yes No

3. Do you/they have a cough?

Yes No

3. Do you/they have a cough?

Yes No

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

Yes No

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

Yes No

5. Have you/they experienced recent loss of taste or smell?

Yes No

5. Have you/they experienced recent loss of taste or smell?

Yes No

6. Are you/they 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

6. Are you/they 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

7. Is your/their age over 60?

Yes No

7. Is your/their age over 60?

Yes No

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

Yes No

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

Yes No

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

Yes No

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

Yes No

Have you received a Covid vaccine?

If yes, which one & when

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.

Your information will be encrypted.

Patient Screening Form

FRANCIS C. CANDRE, DDS