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Patient Screening Questionnaire
Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
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Patient Name:
Your answer
Have you had or experienced a fever, cough, shortness of breath, difficulties breathing, flu-like symptoms (such as GI upset, headache or fatigue) or a loss of taste/smell in the last 21 days? If yes, please explain.
Your answer
Have you been in contact with any confirmed COVID-19 positive patients?
No
Yes
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Do you have heart disease, lung disease, kidney disease, diabetes, or an auto-immune disorder?
Yes
No
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