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Patient Questionnaire

Patient Advisory and Acknowledgement
Receiving Dental Treatment During the COVID-19 Pandemic
 
Today we plan a periodontal evaluation, hygiene visit or treatment that will be done during the COVID-19 pandemic. Please be advised of the following:
Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge. In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening’’ questions below to help us protect our staff, other patients, and yourself.
______________________________________ _______________________
Patient/Responsible Party Date
 
 
Are you currently awaiting the results of a COVID-19 test or do you have COVID-19?  if yes, date of diagnosis  __________________ ______Yes      ______No
Do you have or have you had a fever over the last 21 days? ______Yes      ______No
Do you have or have you had any shortness of breath over the last 21 days? ______Yes      ______No
Do you have or have you had a dry cough over the last 21 days? ______Yes      ______No
Do you have or have you had a runny nose over the last 21 days?
(not due to seasonal allergies) ______Yes      ______No
Do you have or have you had a sore throat over the last 21 days? ______Yes      ______No
Do you have sneezing, watery eyes, and/or sinus pain/pressure that is unusual and not related to seasonal allergies? ______Yes      ______No
Have you experienced headaches, fatigue, or weakness over the last 21 days? ______Yes      ______No
Have you lost your sense of taste and/or smell over the last 21 days? ______Yes      ______No
Within the last 21 days, have you travelled to any foreign country? ______Yes      ______No
Within the last 21 days, have you travelled within the United States? ______Yes      ______No
If so, where?   _____________________________________________________________________
 
Are you experiencing a dental problem that needs to be checked by a Doctor?   ____Yes  ______No
Temperature:  ________________  F

 

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