Susanville Patient Screening Form

Patient Name:*

First NameLast Name

DOB*

Date

Pre-Screening Date*

Today's Date

When is the patient's scheduled appointment?*

Scheduled Appointment Date

PRE-APPOINTMENT SCREENING:*

Rows	Yes	No
Do you/they have a fever or have you/they felt hot or feverish recently? (14/21 days)
Are you/they having shortness of breath or other difficulties breathing?
Do you/they have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you/they experienced recent loss of taste or smell?
Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Have you/they traveled in the past 14 Days to any regions effected by COVID-19? (As relevant to your location)
Is your/their age over 60?

OFFICE USE ONLY, DO NOT FILL IN

Rows	Yes	No
Do you/they have a fever or have you/they felt hot or feverish recently? (14/21 days)
Are you/they having shortness of breath or other difficulties breathing?
Do you/they have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you/they experienced recent loss of taste or smell?
Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Have you/they traveled in the past 14 Days to any regions effected by COVID-19? (As relevant to your location)
Is your/their age over 60?

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with effective dental treatment.

If under 18, parent/guardian signature OR Patient Signature:*

Susanville Team Member Witness:

Patient Screen Form