Patient Screening Form Patient Name * First Name Last Name Today's Date * - Month - Day Year Date Do you/they have fever or have you/they felt hot or feverish recently (14-21days)? * Yes No Are you/they having shortness of breath or other difficulties breathing? * Yes No Do you/they have a cough? * Yes No Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? * Yes No Have you/they experienced 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 other auto-immune disorders? * Yes No Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) * Yes No Thank you. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment. Submit Should be Empty: