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), One Dental Place is taking precautions to lessen the spread of the virus. All patients, employees and independent contractors must have a screening form completed.

Please review the following self screening criteria: *

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)

If answered YES to any of the above questions, a team member One Dental Place 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's Name: *

First Name Last Name
Gender
Signature: *

Clear
Date: *

Month Day Year
Date
Temperature *
Should be Empty:

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