Supplemental Health Questionnaire

SUPPLEMENTAL HEALTH QUESTIONNAIRE

Linsky Dental Group
If you have been exposed to a communicabale disease, you may spread the disease to the Dentist, Dental staff or other patients in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:

Do you or anybody else you have been in contact with have any of the following symptoms?

Note: Mask mandatory prior entering building
Fever (defined as above 100.4 F) ?
Chills?
Cough?
Sore Throat?
Shortness of breath and/or trouble breathing?
Persistent muscle pain, pressure of tightness in the chest?
New loss of taste or smell?
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?
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?
I understand that if the answer to any of these questions is yes, I may be asked to reschedule today's appointment to a later date.
Patient Name

First NameLast Name
Parent/Guardian Name (if applicable)

First NameLast Name
Signature
Date

MonthDayYear
Date
Should be Empty:

SUPPLEMENTAL HEALTH QUESTIONNAIRE