COVID-19 Screening Form Patient/Parent/Guardian Name First Last Patient Email Do you have a fever or above normal temperature (> 100.4° F)? Yes No Are you experiencing shortness of breath or having trouble breathing? Yes No Do you have a dry cough? Yes No Do you have a runny nose? Yes No Have you recently lost or had a reduction in your sense of smell or taste? Yes No Do you have a sore throat? Yes No Are you experiencing chills or repeated shaking with chills? Yes No Do you have unexplained muscle pain? Yes No Do you have a headache? Yes No Even if you don't currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days? Yes No Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days? Yes No Have you been tested for COVID-19 in the last 14 days? If "no," proceed to next question. Yes No If yes, what is the result of the testing? No If negative, proceed to next question. Unsure If still waiting on results, schedule appointment after results are known. Positive Have you traveled more than 100 miles from your home in the last 14 days? Yes No Patient signature required at appointment: I agree to notify the dental practice if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days.By checking this box you confirm that all of this information is true and accurate I do Δ
