duanorthodontics.com-HEALTH QUESTIONNAIRE

SUPPLEMENTAL

HEALTH QUESTIONNAIRE

Orthodontic Treatment in the Era of COVID-19
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:

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?

Yes

Fever (defined as above 99.6 degrees)?

Cough?

Shortness of breath and/or trouble breathing?

Persistent pain, pressure, or tightness in the chest?

Have you, your child, others accompanying you to today’s appointment or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease?

If yes provide approximate dates of illness:
Symptom start date

Month Day Year
Symptom end date

Month Day Year
Patient Name

First Name Last Name
Parent/ Guardian Name (if applicable)

First Name Last Name
Relation
Patient/ Parent/ Guardian Signature

Clear
Date

Month Day Year
Should be Empty: