COVID‐19 PANDEMIC ‐ PATIENT SCREENING FORM


 Are you experiencing shortness of breath or having trouble breathing?
 
 
Do you have a dry cough?
 
 
Do you have a runny nose?
 
 
Have you recently lost or had reduction in your sense of smell or taste?


Do you have a sore throat?


Are you experiencing chills or repeated shaking with chills?

 
Do you have unexplained muscle pain?
 
 
Do you have a headache?

 
Are you experiencing nausea, vomiting or diarrhea?

 
If you don't currently have any of the above symptoms, have you experienced any symptoms in the last 14 days?

 
Have you been in unprotected contact with someone who has tested positive for COVID-19 in the last 14 days?
Unprotected contact means without the use of personal protective equipment.


Have you been tested for COVID-19 in the last 14 days?
 
 
If so, what were the results?
If waiting on results or unsure, reschedule appointment after results known.
 
 
Have you received at least one dose of the COVID-19 vaccination?
 
 
I agree to notify the dental practice if within 2 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had close contact with tested positive for COVID-19 within 2 days.