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
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