COVID Questionnaire

COVID Questionnaire

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:
Patient Name*

First NameMiddle NameLast Name
Responsible Party
E-mail Address*
example@example.com
Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease?*

YesNo
If yes, when?
Do you, your child, or others accompanying you to today’s appointment or other recent acquaintances have:
A Fever (defined as above 99.6 degrees)?*

YesNo
A Cough?*

YesNo
Shortness of Breath and/or Trouble Breathing?*

YesNo
Persistent Pain, Pressure, or Tightness in the Chest?*

YesNo
Signature
I understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s orthodontic appointment.
Patient/Parent’s Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Signature