SUPPLEMENTAL HEALTH QUESTIONNAIRE

AAOIC SUPPLEMENTAL HEALTH QUESTIONNAIRE
If you have been exposed to a communicable disease, you may spread the disease to the orthodontist, orthodontic staff, or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission.
Have you, your child, or other accompanying you to today's appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable?

Yes No
If yes, when?
Do you, your child or others accompanying you to today's appointment or orther recent acquaintances have:
A fever (defined as above 99.6 degrees)

Yes No
A Cough?

Yes No
Shortness of Breath and/or Trouble Breathing?

Yes No
Persistent Pain, Pressure, or Tightness in the Chest?

Yes No
I understand that if the answer to any of these questions is yes, I will be asked to reschedule today's orthodontics appointment.
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AAOIC SUPPLEMENTAL HEALTH QUESTIONNAIRE