Supplemental Health Questionnaire
If you have been exposed to a communicable disease, you may spread the disease to the dentist, dental 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:
Patient Name
*
First Name
Last Name
Parent/Guardian Name (if applicable)
First Name
Last Name
Relationship to Patient
Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease?
*
Yes
No
If yes, when?
Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances traveled outside the our local area or outside the US within the past 14 days?
*
Yes
No
If yes, when?
Do you, your child, others accompanying you today or anyone else you have recently been in contact with have any of the following symptoms?
Fever? (defined as above 100.4°F or 38°C)
*
Yes
No
Chills?
*
Yes
No
Cough?
*
Yes
No
Sore Throat?
*
Yes
No
Shortness of Breath and/or Trouble Breathing?
*
Yes
No
Persistent Muscle Pain, Pressure or Tightness in the Chest?
*
Yes
No
New Loss of Taste or Smell?
*
Yes
No
Flu-like Symptoms such as Gastrointestinal Upset, Headache, or Fatigue?
*
Yes
No
If yes, provide approximate dates of illness.
Symptom Start Date
-
Month
-
Day
Year
Date
Symptom End Date
-
Month
-
Day
Year
Date
Signature of Parent or Guardian
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: