PATIENT SCREENING FORM Patient Name *Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? *YESNOAre you/they having shortness of breath or other difficulties breathing? *YESNODo you/they have a cough? *YESNOAny other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *YESNOHave you/they experienced recent loss of taste or smell? *YESNOAre you/they in contact with any confirmed COVID-19 positive patients? *YESNOPatients who are we// but who have a sick family member at home with COVID-19 should consider postponing elective treatment. *YESNOIs your/their age over 60? *YESNODo you/they have heart disease, lung disease, kidney disease, diabetes or any autoimmune disorders? *YESNOHave you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) *YESNOPositive 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 Send Message
