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English (US)
Spanish (Latin America)
SUPPLEMENTAL HEALTH QUESTIONNAIRE
If you have been exposed to a communicable disease, you may spread the disease to the orthodontist, orthodontic staff or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:
Patient's Name
*
First Name
Last Name
Have you, your child or others accompanying you to today’s appointment tested positive for or been diagnosed as having COVID-19?
*
Yes
No
Do you, your child, others accompanying you to today's appointment or anyone you have recently been in contact with have any of the following symptoms?
*
Fever? (defined as above 100.4 F degrees)
Cough?
Shortness of breath and/or trouble breathing?
Persistent pain, pressure, or tightness in the chest?
No
Have you, your child or others accompanying you to today's appointment or anyone you have recently been in contact with tested positive or been diagnosed as having COVID-19 or any other communicable disease?
*
Yes
No
If yes, please provide approximate symptom start date:
-
Month
-
Day
Year
Date
If yes, please provide approximate symptom end date:
-
Month
-
Day
Year
Date
Patient/Parent Signature. I understand that if the answer to any of these questions is yes, I may be asked to reschedule today’s orthodontic appointment.
*
Clear
Submit
Should be Empty: