Patient Screening Form

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