COVID Patient Screen

Please correct the errors described below.

First Name

Last Name

Patient Screening Questionnaire

Please answer the following questions based on your pre-appointment state.

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

Yes No

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

Yes No

Do you/they have a cough?

Yes No

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

Yes No

Are you/they in contact with any confirmed COVID-19 positive patients?

Yes No

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

Is your/their age over 60?

Yes No

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

Yes No

Have you/they traveled in the past 14 days?

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.

Signature

The information given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform the office of any changes

Signature of Patient, Parent, or Guardian

Date

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