COVID-19 Health Questionnaire

Covid-19 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:

Do you, your child, others accompanying you to today's appointment or anyone you have recently been in contact with have any of the following symptoms?
Today's Date

Month Day Year
Patient Name

First Name Last Name
Fever (defined as above 100.4° F degrees)?

Yes No
Is the patient having shortness of breath or other difficulties breathing?

Yes No
Does the patient have a cough?

Yes No
Does the patient have any flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes No
Has the patient experienced recent loss of taste or smell?

Yes No
Has the patient been in contact with any confirmed COVID-19 positive patients?

Yes No
Does the patient have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Yes No
Has the patient traveled outside of Hawaii in the past 14 days?

Yes No
I understand that if the answer to any of these questions is yes, I may be asked to reschedule today’s orthodontic appointment to a later date.
Patient/Parent/Guardian Signature:

Clear
Should be Empty:

Covid-19 Health Questionnaire