ADA Patient Screening Form

ADA Patient Screening Form
Patient Name

First Name Last Name
Today's Date

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

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

Yes No
Do you have a cough?

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

Yes No
Have you 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?

Yes No
For Office Staff

Patients do not need to fill out this portion
Today's Date

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

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

Yes No
Do they have a cough?

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

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

Yes No
Are 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 their age over 60?

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

Yes No
Have they traveled in the past 14 days?

Yes No
Should be Empty:

ADA Patient Screening Form

For Office Staff