CORONA VIRUS SCREENING QUESTIONNAIRE

Name*

First Last

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*

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 recent loss of taste or smell?*

Yes
No

Are you/they in contact with any confirmed COVID-19 positive patients?*

Yes
No

Is your/their age over 60?*

Yes
No

Do you/they have heart disease, lung disease, kidney disease, diabetes or any 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

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

Questionnaire

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