COVID-19 Screening Form (PRE-APPOINTMENT CHECK) COVID-19 Screening Form (PRE-APPOINTMENT CHECK) Patient First Name * Patient Last Name * Email * Date of Appointment * 1. Have you previously been diagnosed with COVID-19, or do you think you've had/have COVID-19? * Yes No If NO to Question 1, skip to Question 5 2. If Yes, when and how were you confirmed positive? I think I had it I had a positive nasal swab test I had a positive blood test I had a positive saliva test I currently have symptoms and am waiting for a test Section 3. If you have had COVID-19, how were you confirmed negative? I was diagnosed negative by a nasal swab test. How many times? How far apart? days 3. If you have had COVID-19, how were you confirmed negative? I show antibodies to COVID19 with a blood test My doctor said I no longer have it, because I don't have any symptoms I don't have any symptoms, so I don't have it 4. If you have had COVID-19, when were you confirmed negative? 24 hours ago Today 10 days after testing 5. Do you currently have (or have you experienced) any of the following symptoms in the past 21 days? Fever * YES NO Fatique (feeling tired) * YES NO Altered or loss of taste/smell * YES NO Dry Cough * YES NO Trouble breathing * YES NO Shortness of breath, difficulty breathing, chest tightness * YES NO Confussion * YES NO Blueish lips or face * YES NO Chills/Repeated shaking with chills * YES NO Muscle pain * YES NO Headache or soar throat * YES NO Any other flu-like symptoms * YES NO GI upset or diarrhea * YES NO 6. Are you in contact with anyone who has been sick/or confirmed to COVID-19 positive * YES NO 7. In the past 14 days have you traveled to any region affected by COVID-19? * YES NO Some medical conditions have been associated with more severe COVID-19 disease. The following questions are an attempt to determine your risk: 8. Are you over age 65? * YES NO 9. Do you have high blood pressure? * YES NO If you have high blood pressure, is it controlled? YES NO 10. Do you have diabetes? * YES NO 11. Are you overweight? * YES NO No answer 13. Do you have any autoimmune disorders? * YES NO 14. Are there any other conditions you would like to report * YES NO OtherOther I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. Signature * signature keyboard Clear Submit
