HEALTH QUESTIONNAIRE

HEALTH QUESTIONNAIRE
Dental Treatment in the Era of COVID-19

If you have been exposed to a communicable disease, you may spread the disease to the dentist, dental staff, or other patient/patients in practice. Therefore, before your appointment, we will ask the following questions to reduce the chances of transmission:
Do you, your child, others accompanying you to today's appointment or anyone you have recently been in contact with have any of the following symptoms? Fever (defined as above 99.6 degrees)?*

YesNo
Cough?*

YesNo
Shortness of breath and/or trouble breathing?*

YesNo
Persistent pain, pressure, or tightness in the chest?*

YesNo
Have you, your child, others accompanying you to today's appointment or anyone you have recently been in contact with, tested positive for, or been diagnosed as having COVID-19 or any other communicable disease?*

YesNo
If yes, provide approximate dates of illness

MonthDayYear
Date
I understand that if the answer to any of these questions is yes, I may be asked to reschedule today's appointment to a later date.
Patient/Parent's Signature*

Clear
Date*

MonthDayYear
Date
Vaccine Brand Name
Date of Vaccine 1st Dose

MonthDayYear
Date
Date of Vaccine 2nd Dose

MonthDayYear
Date
Date of Vaccine 3rd Dose

MonthDayYear
Date
Should be Empty: