ONSITE DENTAL CARE COVID-19 PATIENT QUESTIONNAIRE

*Indicate Yes or No and provide revelant comments.

PATIENT NAME

DATE OF APPOINTMENT

Screening Question

Pre Appointment

At Appointment

Do you have a fever or have you felt feverish within last 14 days?

Do you have a cough?

Are you having shortness of breath or difficulty breathing?

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

Do you have any recent loss of taste or smell?

Are you in contact with anyone who has been confirmed to be COVID 19 positive?

Have you traveled in the past 14 days to any regions affected by COVID 19

Do you have:

Heart Disease

Lungs Disease

Kidney Disease

Diabetes

Autoimmune Disorders

Signature of Resident/Responsible Party or Person Completing Form

Initial of Dr Reviewing Form

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