COVID-19 PATIENT SCREENING QUESTIONNAIRE

COVID-19 SCREENING QUESTIONNAIRE

In response to the recent Coronavirus (COVID-19) outbreak and the raised pandemic alert status by the World Health Organization (WHO), Tanada Lee Family Dental Care is taking precautions to lessen the spread of the virus. All legal guardians and patients must have a screening form completed.

Please review the following self screening criteria: *

Rows	Yes	No
Do you/they have 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.)
Is your/their age over 60?
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 affected by COVID-19? (as relevant to your location)

If answered YES to any of the above questions, a team member Tanada Lee Family Dental Care will reschedule you and your child(ren)’s dental appointment. Please contact your doctor for further advice.

If you do not meet the criteria above, please sign below indicating that you have been provided with this information.

I HAVE REVIEWED THE ABOVE CRITERIA. MY CHILD(REN) AND I DO NOT HAVE SYMPTOMS AS DESCRIBED. (Please list the full name and date of birth of each child present at today's appointment.)

Patient Name(s)/ Date of Birth:*

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Legal Guardian Name:*

First NameLast Name

Relationship to Patient(s):*

Signature:(initial)*

Date:*

Date