Patient Screening Form

Patient Screening Form
Patient Name *

First Name Middle Name Last Name
Date *

Month Day Year
Date

Yes

Are you or anyone in your household awaiting test results or tested positive for COVID-19 in the last 14 days?

Have you or anyone in your household been in contact with anyone confirmed positive for COVID-19 in the last 14 days?

Have you or anyone in your household traveled to any region with a high rate of COVID-19 in the last 14 days?

Have you or anyone in your household been asked to self quarantine within the last 14 days?

Have you or anyone in your household had any flu-like symptoms in the last 14 days?

Have you experienced any shortness of breath or other difficulties breathing?

Are you experiencing any other symptoms, such as gastrointestinal upset, headache, fatigue, muscle aches, vomiting, malaise, diarrhea or loss of taste or smell?

Positive responses to any of these questions would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
Should be Empty: