PRE-APOINTMENT SCREENING

PATIENT SCREENING FORM, COVIDPATIENT SCREENING FORM, COVID-19
Patient Name *
PRE-APOINTMENT SCREENING
Date: *

Month Day Year
Date
Do you have fever or have you felt hot or feverish recently (14-21 days)? *

Yes No
Are you having shortness of breath or other difficulties breathing? *

Yes No
Do you have a cough? *

Yes No
Any other flu-like symptoms, suchsuch as gastrointestinal upset, headache or fatigue *

Yes No
Have you experienced recent loss of taste or smell? *

Yes No
Are you in contact with any confirmedconfirmed COVID-19 positive patients? Patients who are well but who have a sicksick family member at home with COVID-19 should consider postponing electiveelective treatment. *

Yes No
Is your age over 60? (for adult orthodontic patient) *

Yes No
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immunedisorders? *

Yes No
Have you traveledin the past 14 days to any regions affected by COVID-19?(as relevant to your location) *

Yes No
Patient's/Guardian's Signature *

Clear
Guardian's Name:
Please verify that you are human *
Should be Empty: