Pre-Screening Form-CG

Excellence in Dentistry - WI
1001 North Sherman Avenue - Madison, WI 53704 - 608-240-1001

Excellence in Dentistry - WI
226 West Cottage Grove Rd - Cottage Grove, WI 53527 - 608-839-4554

Date

Full Name *

First Name Last Name

DOB: *

Date

Your estimate of overall health:

Excellent Good Fair Poor

Questions - Required *

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.

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immunedisorders? Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immunedisorders?

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) 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.