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AGPOON DENTAL PATIENT SCREENING FORM
02 86643760 / 09662718244
@agpoondental
agpoondental@gmail.com
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Full Name (Last, First, Middle)
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Contact No.
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Date of Birth
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DD
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Age
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Sex
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Male
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Are you currently experiencing a DENTAL EMERGENCY? Please specify/describe your case or REASON for appointment
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Date of Appointment
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Time of Appointment
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Time
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COVID SCREENING FORM
PLEASE ANSWER HONESTLY
Medical History. Do you have any of the following?
High Blood Pressure
Low Blood Pressure
Epilepsy/Convulsions
AIDS or HIV infection
Sexually Transmitted Disease
Stomach Troubles/Ulcers
Rapid Weight Loss
Joint Replacement/Implant
Heart Surgery
Heart Attack
Thyroid Problem
Heart Disease
Heart Murmur
Hepatitis/Liver Disease
Rheumatic Fever
Allergies
Respiratory problems
Hepatitis/Jaundice
Tuberculosis
Swollen ankles
Kidney Disease
Diabetes
Chest pain
Stroke
Cancer/Tumors
Anemia
Asthma
Bleeding Problems
Emphysema
Arthritis
Other:
Do you have any of the following symptoms?:
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NO SYMPTOMS
New and persistent cough
Shortness of breath or any difficulty breathing
Fever
Headache
Sore throat
Runny Nose
Chills
General Malaise
Diarrhea
Other:
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Have you been in contact with anyone in the last 14 days who is experiencing these symptoms?
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Yes
No
Maybe
Have you been in contact with anyone who has since tested positive for Covid-19? *
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Yes
No
Maybe
Have you travelled abroad for the last 1-2 months? (Y/N) Where did you go?
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Is there anything else we should know before treating you?
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