SUPPLEMENTAL HEALTH QUESTIONNAIRE

SUPPLEMENTAL HEALTH QUESTIONNAIRE

Orthodontic Treatment in the Era of COVID-19
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:
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?*

YesNo
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? Cough?*

YesNo
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? Shortness of breath and/or trouble breathing?*

YesNo
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? 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
through

MonthDayYear
Date
I understand that if the answer to any of these questions is yes, I may be asked to reschedule today’s orthodontic appointment to a later date.
Patient Name*
Parent/Guardian Name (if applicable)*
Relation
Parent/Guardian Name (if applicable)

Clear
Date*

MonthDayYear
Date
Should be Empty: