COVID-19 Screening Questionnaire
Prior to your next appointment, please complete this brief questionnaire.
Sign in to Google to save your progress. Learn more
PLEASE FILL THIS OUT NO SOONER THAN 24hr PRIOR TO YOUR APPOINTMENT
Please type your currently scheduled appointment date/time
First and Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Do you/they have a fever or have you/they felt hot or feverish recently (14-21 days)? *
Required
Are you/they having shortness of breath or other difficulties breathing? *
Required
Do you/they have a cough? *
Required
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *
Required
Have you/they experienced a recent loss of taste or smell? *
Required
Are you/they in contact with any confirmed COVID-19 positive patients? *
Required
Is your/their age over 60? *
Required
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? *
Required
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) *
Required
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
By initialing the box below, you agree that you have answered completely and truthfully. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Retain & Smile. Report Abuse