Corona Virus Screening Questionnaire

Name*

First Last

Date of Birth*

Do you/they have fever or you/they felt hot or feverish recently (14-21 days)*

Yes
No

Are you/they having shortness of breath or 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

Have you /they experienced recent loss of taste or smell?*

Yes
No

Are you/they in contact with any confirmed COVID-19 positive patients?*

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 ?*

Yes
No

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 to proceeding with elective dental treatment.

Signature of Patient or Legal Guardian*

Comments

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