Patient Screening Questions
Please complete the below questionnaire prior to your visit.
First Name
Looks good!
Last Name
Date of Birth
Do you have a fever or have you felt hot or feverish recently?
Yes
No
Are you having shortness of breath or other difficulties breathing?
Yes
No
Do you have a cough?
Yes
No
Are you experiencing any other cold or flu-like symptoms, such as gastrointestinal discomfort, headache or fatigue?
Yes
No
Have you experienced recent loss of taste or smell?
Yes
No
Are you in contact with any confirmed COVID-19 positive patients?
(Any patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment)
Yes
No
Are you over 60?
Yes
No
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Yes
No
Are you pregnant?
Yes
No / NA
Comments
Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.
Submit
