COVID-19 Screening Form

Patient Name
Date

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

YesNo
Are you/they having shortness of breath or other difficulties breathing?

YesNo
Do you/they have a cough?

YesNo
Any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?

YesNo
Have you/they experienced recent loss of taste or smell?

YesNo
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.*

YesNo
Is your/their age over 60?*

YesNo
Do you/they have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?*

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

YesNo
Have you been fully vaccinated?*

YesNo
If yes, which vaccine?
Date

MonthDayYear
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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