AAO supplemental health questionnaire

SUPPLEMENTAL HEALTH QUESTIONNAIRE

Orthodontic Treatment in the Era of COVID-19
If you have been exposed to a communicabale 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 today or anyone else you have recently been in contact with have any of the following symptoms?
Fever (defined as above 100.4 F) ? *

Yes No
Chills? *

Yes No
Cough? *

Yes No
Sore Throat? *

Yes No
Shortness of breath and/or trouble breathing? *

Yes No
Persistent muscle pain, pressure of tightness in the chest? *

Yes No
New loss of taste or smell? *

Yes No
Have you or others accompanying you to today's appointment traveled outside of our local area or outside the US within the past 14 days? *

Yes No
Have you, your child, others accompanying you today or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease? *

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. *

I understand
Patient Name

First Name Last Name
Parent/Guardian Name (if applicable)

First Name Last Name
Signature

Clear
Date *

Month Day Year
Date
Should be Empty:

SUPPLEMENTAL HEALTH QUESTIONNAIRE