Patient Name

    Date of Birth

    Do you have fever or have you/they felt hot or feverish recently (14-21 days)?

    Are you/they having shortness of breath or other difficulties breathing?

    Do you/they have a cough?

    Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

    Have you/they experienced recent loss of taste or smell?

    Are you/they in contact with any confirmed COVID-19 positive patients?

    Is your/their age over 60?

    Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

    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.