COVID-19 Screening Form

Patient Name
Date

Month Day Year
Date
Do you/they have a fever, or have you/they felt hot or feverish recently (14-21 days)?

Yes No
Are you/they having shortness of breath or other difficulties breathing?

Yes No
Do you/they have a cough?

Yes No
Any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?

Yes No
Have you/they experienced recent loss of taste or smell?

Yes No
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. *

Yes No
Is your/their age over 60? *

Yes No
Do you/they have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders? *

Yes No
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) *

Yes No
Have you been fully vaccinated? *

Yes No
If yes, which vaccine?
Date

Month Day Year
Date
Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

For testing, see the list of State and Territorial Health Department Websites for your specific area's
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