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MEDICAL QUESTIONNAIRE
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PATIENT SCREENING
FORM
First Name *
Last Name *
Date of Birth
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
*
Yes
No
Do 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, headache or fatigue?
*
Yes
No
Do 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 affected by COVID-19? (as relevant to your location)
*
Yes
No
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.
Please sign your name.
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SUBMIT
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