AAO Supplemental Health Questionnaire Form

SUPPLEMENTAL HEALTH QUESTIONNAIRE

Orthodontic Treatment in the Era of COVID-19

If you have been exposed to a communicable 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:

Patient Name

Responsible Party

Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease?

Yes No

If yes, when? Date

Do you, your child, or others accompanying you to today’s appointment or other recent acquaintances have:

• A Fever (defined as above 99.6 degrees)

Yes No

• A Cough?

Yes No

• Shortness of Breath and/or Trouble Breathing?

Yes No

• Persistent Pain, Pressure, or Tightness in the Chest?

Yes No

I understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s orthodontic appointment.

Patient/Parent’s Signature

Date

1820 SW VERMONT STREET, SUITE O, PORTLAND, OREGON 97219

P. 503.246.9802 F. 503.246.9995 GARFINKLEORTHO.COM

SUPPLEMENTAL HEALTH QUESTIONNAIRE

Orthodontic Treatment in the Era of COVID-19