Patient Screening Form

Patient Name *

Date *

Email *

Phone *

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

Yes

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

Yes

Do you/they have a cough? *

Yes

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

Yes

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

Yes

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

Yes

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

Do you/they have any rash or rash like symptoms? *

Yes

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

Yes

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

Yes

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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.