AAO supplemental health questionnaire

If you have been exposed to a communicabale disease, you may spread the disease to the orthodontist, orthodontic staff or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:

Do you, your child, others accompanying you today or anyone else you have recently been in contact with have any of the following symptoms?

Fever (defined as above 100.4 F) ?*

YesNo

Chills?*

YesNo

Cough?*

YesNo

Sore Throat?*

YesNo

Shortness of breath and/or trouble breathing?*

YesNo

Persistent muscle pain, pressure of tightness in the chest?*

YesNo

New loss of taste or smell?*

YesNo

Have you or others accompanying you to today's appointment traveled outside of our local area or outside the US within the past 14 days?*

YesNo

Have you, your child, others accompanying you today or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease?*

YesNo

I understand that if the answer to any of these questions is yes, I may be asked to reschedule today's orthodontic appointment to a later date.*

I understand

Patient Name

First NameLast Name

Parent/Guardian Name (if applicable)

First NameLast Name

Signature

Date*

Date

SUPPLEMENTAL HEALTH QUESTIONNAIRE