Patient's Name
PRE-APPOINTMENT
Date:
IN-OFFICE
Date:
Do you have a fever or have you/they felt hot or feverish recently (14-21 days)?
Yes
No
Yes
No
TEMPERATURE reading:
Yes
No
Yes
No
Have you had shortness of breath or other difficulties breathing?
Yes
No
Yes
No
Do you have any flu-like symptoms, such as, cough, headache or fatigue, loss of smell or taste?
Yes
No
Yes
No
Do you have any history of heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Yes
No
Yes
No
Have you been in contact with any confirmed COVID-19 positive patients? If yes, when were you in contact with them?
Date?
Yes
No
Yes
No
Have you tested positive for COVID-19 in the past 14 days? If yes, what was the date of testing?
Yes
No
Yes
No
Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
Yes
No
Yes
No
*Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
Staff Initials