Patient Name*I am filling out this form:*SelectPre-AppointmentIn-OfficeToday's Date* Date Format: MM slash DD slash YYYY Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*YesNoAre you/they having shortness of breath or other difficulties breathing?*YesNoDo you/they have a cough?*YesNoAny other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*YesNoHave you/they experienced recent loss of taste or smell?*YesNoAre 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.YesNoIs your/their age over 60?*YesNoDo you/they have heart disease, lung disease, kidney disease, diabetes or any autoimmune disorders?*YesNoHave you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)*YesNoPositive 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.
