IN OFFICE SCREENING
Patient Name
*
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 confirmedconfirmed COVID-19 positive patients? Patients who are well but who have a sicksick family member at home with COVID-19 should consider postponing electiveelective 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-immunedisorders?
*
Yes
No
Have you traveled in the past 14 days to any regions outside of the Bay Area and 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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