Burks COVID19 PRE-SCREENING

PRE-SCREENING FORM

Burks Dentistry 103 Cude Lane Madison, TN 37115 (615) 851-7999
PATIENT NAME: *
DATE:

Month Day Year
Date

Type a question *

Yes

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)

Positive responses to any of these indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
Should be Empty:

PRE-SCREENING FORM