PATIENT SCREENING FORM

Patient name

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 we// but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

YES

Is your/their age over 60?

YES

Do you/they have heart disease, lung disease, kidney disease, diabetes or any autoimmune disorders?

YES

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

YES

Free Text

Positive responses to any of these would likely Indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

For testing please visit this website for specific areas of information on state & territorial health department websites

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954-987-3309

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