COVID-19 Patient Screening Form Patient Name Pre-Appointment Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? YesNo Are you/they having shortness of breath or other difficulties breathing? YesNo Do you/they have a cough? YesNo Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? YesNo Have you/they experienced recent loss of taste or smell? YesNo 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. YesNo Is your/their age over 60? YesNo Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? YesNo Today's Date: Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment. For testing, see the list of State and Territorial Health Department Websites for your specific area's information. New Patient Documents For full functionality, please download and open the forms with the Adode Acrobat Reader, rather than just your web browser.