ext Patient Name: PRE-APPOINTMENT IN-OFFICE Do you/they have a fever or have you/they felt hot or feverish recently (14-21 days)? YesNo YesNo Are you/they having shortness of breath or other difficulties breathing? YesNo YesNo Do you/they have a cough? YesNo YesNo Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? YesNo YesNo Have you/they experienced recent loss of taste or smell? YesNo 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 withCOVID-19 should consider postponing elective treatment. YesNo YesNo Is your/their age over 60? YesNo YesNo Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? YesNo YesNo Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) YesNo YesNo Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment. For testing, see the list of State and Territorial Health Department Websites for your specific area’s information
Dr. Elizabeth Kitsos Pediatric Dentistry | Garden City, NYDr. Elizabeth Kitsos Pediatric Dentistry | Garden City, NY
