chuyangdental.com-Covid-19 Patient Screening Form

Instructions for use: Use one form for each patient appointment. Ask the patient these questions at the time appointment is made or with appointment reminder, and again no more than two days before the appointment.

Patient/Parent/Guardian Names: *

Date

Are you fully vaccinated for COVID-19?

NoYes

Note:
An individual is considered fully vaccinated if it has been more than 2 weeks since they received the last shot of a 2-dose vaccine (for example, Moderna or Pfizer) or a single dose vaccine (J&J). If the answer is yes, screen for symptoms only and not for close contact, COVID-19 testing or travel. Observational screening, instead of questioning patient about symptoms or having patient complete a form, should be noted in the patient chart.

Do you have a fever or above normal temperature (>100.0˚ F)? Take temperature at appointment.

NoYes

Note:
If patient answers “yes,” note the symptoms reported and seek additional information from the patient about possible cause. If patient does not need emergency care, consider not scheduling or seeing the patient until symptoms resolve.

Are you experiencing more than one of the following symptoms: shortness of breath,dry cough, sore throat, unexplained muscle pain, headache or nausea, new loss or taste or smell?

NoYes

Note:
If patient answers “yes,” note the symptoms reported and seek additional information from the patient about possible cause. If patient does not need emergency care, consider not scheduling or seeing the patient until symptoms resolve.

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

NoYes

Note:
If “yes” and patient does not need emergency care, do not see patient unless it has been more than 10 days since symptoms first appeared and 24 hours of no fever without use of fever-reducing medication.

Have you been advised to quarantine due to close contact with someone diagnosed with COVID-19?

NoYes

Note:
If yes, ask when the quarantine period ends and set appointment time after that date.

Have you been tested for COVID-19 in the last 14 days? If “no,” proceed to next question.

NoYes

If yes, what is the result of the testing?
No Unsure Positive

If negative, proceed to next question.

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

Note:
If positive, determine if patient needs emergency care. If not an emergency, schedule patient to be seen when it has been more than 10 days (20 days if patient illness was severe) since symptoms first appeared and 24 hours of no fever without use of fever reducing medication.

Have you traveled out of state or out of country in the last 14 days?

NoYes

Note:
Fully vaccinated individuals need not quarantine, according to the CDC. Know your county’s health officer orders with regard to nonessential travel by individuals not vaccinated for COVID-19. The county orders will have quarantine recommendations.

Patient signature required at appointment:
I agree to notify the dental practice if within 2 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 close contact with tested positive for COVID-19 within 2 days.

Acepto dar aviso a la clínica dental si dentro de dos días presento síntomas de COVID-19 o tengo un resultado positivo de COVID-19. Entiendo que la clínica dental tiene la obligación legal y ética de informarme si un miembro del personal con el que tuve contacto ha tenido un resultado positivo de COVID-19 dentro de dos días.

Signature Signature

Covid-19 Patient Screening Form

Screening questions