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Patient Screening Form
Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
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Patient Name
*
Your answer
Do you/they have fever or have you/they felt hot or feverish recently(14-21 days)?
*
Yes
No
Are you/they having shortness of breath or other difficulties breathing?
*
Yes
No
Do you/they have a cough?
*
Yes
No
Any other flu-like symptoms, such as gastrointestinal upset, headacheor fatigue?
*
Yes
No
Have you/they experienced recent loss of taste or smell?
*
Yes
No
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.
*
Yes
No
Is your/their age over 60?
*
Yes
No
Do you/they have heart disease, lung disease, kidney disease,diabetes or any auto-immune disorders?
*
Yes
No
Have you/they traveled in the past 14 days to any regions affectedby COVID-19? (as relevant to your location)
*
Yes
No
Have you/they been vaccinated for COVID-19?
*
Yes
No
Any Additional Information?
Your answer
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