Bridgeport Covid-19 Patient Screening Form

Bridgeport Aesthetic Dentistry

Covid-19 Patient Screening Form

Today's Date

Date

Patient Name *

First Name Last Name

Parent/Guardian Name (if applicable)

First Name Last Name

If patient answers “yes” to either question on shortness of breath or coughing, or answers yes to any combination of two other symptoms and the patient does not need emergency are, consider not scheduling or seeing the patient until symptoms resolve or until patient can provide proof they are not infectious for COVID-19. The dentist may want to seek additional information from the patient regarding symptoms.

Do you have a fever or above-normal temperature (>100.4° F)? Take temperature at appointment. *

No Yes

Are you experiencing shortness of breath or having trouble breathing? *

No Yes

Do you have a dry cough? *

No Yes

Do you have a runny nose? *

No Yes

Have you recently lost or had a reduction in your sense of smell or taste? *

No Yes

Do you have a sore throat? *

No Yes

Are you experiencing chills or repeated shaking with chills? *

No Yes

Do you have unexplained muscle pain? *

No Yes

Do you have a headache? *

No Yes

Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days? *

No Yes

If “yes” and patient does not need emergency care, do not see patient unless it has been more than 7 days since symptoms first appeared and 3 days of no fever without use of fever-reducing medication.

Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days? *

No Yes

If you have been tested for Covid-19 what is the result of the testing?

No (Negative) Unsure Positive

If positive, determine if patient needs emergency care. If not an emergency, schedule patient to be seen when it has been more than 7 days since symptoms first appeared and 3 days of no fever without use of fever-reducing medication.

If still waiting on results, schedule appointment after results are known.

Have you traveled more than 100 miles from your home in the last 14 days? *

No Yes

If yes, determine if patient traveled to an area where COVID-19 cases are high. Determine if patient followed physical distancing precautions and wore a mask while in public. Use professional judgement when determining whether to proceed with the appointment.

Patient signature required at appointment:

I agree to notify the dental practice if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days.

Signature *

Clear