COVID-19 PATIENT SCREENING QUESTIONNAIRE

COVID-19 SCREENING QUESTIONNAIRE
In response to the recent Coronavirus (COVID-19) outbreak and the raised pandemic alert status by the World Health Organization (WHO), Children’s Dental Care is taking precautions to lessen the spread of the virus. All legal guardians and patients must have a screening form completed.

Please review the following self screening criteria:

Rows	Yes	No
Has the patient or anyone in the family (household) tested positive for COVID-19?	1	2
Has the patient or anyone in the family (household) been tested for COVID-19 and are awaiting results?	3	4
Does the patient or anyone in the family (household) have any of the following respiratory symptoms? Fever, Sore Throat, Cough, Shortness of Breath?	5	6
Has the patient or anyone in the family (household) recently lost your sense of smell or taste?	7	8
Does the patient or anyone in the family (household) have any GI symptoms? Diarrhea? Nausea?	9	10
Even if you don’t currently have any of the above symptoms, has the patient or anyone in the family (household) experienced any of these symptoms in the last 14 days?	11	12
Has the patient or anyone in the family (household) been in contact with someone who has tested positive for COVID-19 in the last 14 days?	13	14
Has the patient or anyone in the family (household) traveled outside the United States by air or cruise ship in the past 14 days?	15	16
Has the patient or anyone in the family (household) traveled within the United States by air, bus or train within the past 14 days?	17	18

If answered YES to any of the above questions, a team member of Children’s Dental Care will reschedule your child(ren)’s dental appointment. Please contact your doctor for further advice.
If you do not meet the criteria above, please sign below indicating that you have been provided with this information.
I HAVE REVIEWED THE ABOVE CRITERIA. MY CHILD(REN) AND I DO NOT HAVE SYMPTOMS AS DESCRIBED. (Please list the full name and date of birth of each child present at today's appointment.)
Patient Name(s)/ Date of Birth:
Legal Guardian Name:
First NameLast Name
Relationship to Patient(s):
Signature:
Clear
Date:
MonthDayYear
Date
Should be Empty: