Patient Screening Form

Patient Name

	PRE-APPOINTMENT	IN-OFFICE
	Date	Date
Do you/they have 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 with COVID-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.