Patient Name
Date of Birth
Do you have fever or have you/they felt hot or feverish recently (14-21 days)? YesNo
Are you/they having shortness of breath or other difficulties breathing? YesNo
Do you/they have a cough? YesNo
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? YesNo
Have you/they experienced recent loss of taste or smell? YesNo
Are you/they in contact with any confirmed COVID-19 positive patients? YesNo
Is your/their age over 60? YesNo
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? YesNo
Today's Date:
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
