This screening form should be used twice; once during pre-screening (e.g. over the phone when confirming theappointment), and a second time when the patient presents at the office for their appointment. Answers tothese questions must be documented in the patient record.

Patient Name
1. Have you tested positive for COVID-19 or have been advised by your physician or local public health department to self-isolate?

2. Do you have or recently had (14-21 days) any of the following symptoms:

Fever or feeling hot, chills/feverish
Shortness of breath or other difficulties breathing
Cough or worsening of a chronic cough
Flu-like symptoms such as stomach upset, diarrhea, headache, or fatigue
Recent alteration or loss of taste or smell
Any new, unusual symptoms, e.g., malaise or sudden onset of runny nose
3. Have you been in contact with anyone with confirmed COVID-19 or with any of the above symptoms of possible COVID-19?
4. Do you have heart, lung or kidney disease, diabetes, or any auto-immune disorders?
5. Have you travelled in the past 14 days to any COVID-19 hot spots?
6. Have you been in gatherings of more than 10 people?
7. Have you not been practicing social distance?

“YES” responses to any of these questions would indicate the need for a deeper discussion with the dentistbefore proceeding with treatment. Whenever possible, patients with one or more risk factors should berescheduled to a later date.

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