Patient Name:

    QUESTIONS

    PRE-APPOINTMENT DATE:

    Do you/they have fever or have you/they felt hot or feverish recently

    YesNo

    Are you/they having shortness of breath or other difficulties breathing?

    YesNo

    Do you/they have a cough?

    YesNo

    Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

    YesNo

    Have you/they experienced recent loss of taste or smell?

    YesNo

    Are you/they in contact with any confirmed COVID-19 positive patients?Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

    YesNo

    Is your/their age over 60?

    YesNo

    Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

    YesNo

    Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

    YesNo

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

    Should you develop any of the above signs or symptoms within 14 days of your appointment with our office, please call and let us know.

    For testing, see the list of State and Territorial Health Department Websites for your specific area’s information.