Wellness Screening Form

    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.