PATIENT SCREENING FORM, COVID
PATIENT SCREENING FORM, COVID
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19
Patient Name
*
PRE-APOINTMENT SCREENING
Date:
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have fever or have you felt hot or feverish recently (14-21 days)?
*
Yes
No
Are you having shortness of breath or other difficulties breathing?
*
Yes
No
Do you have a cough?
*
Yes
No
Any other flu-like symptoms, suchsuch as gastrointestinal upset, headache or fatigue
*
Yes
No
Have you experienced recent loss of taste or smell?
*
Yes
No
Are you 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 age over 60? (for adult orthodontic patient)
*
Yes
No
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
*
Yes
No
Have you traveledin the past 14 days to any regions affected by COVID-19?(as relevant to your location)
*
Yes
No
Patient's/Guardian's Signature
*
Guardian's Name:
Please verify that you are human
*
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