Covid-19 Symptom Screening

Patient Name:

Date:

Do you have a fever or have you felt hot or feverish recently
(in the past 14-21 days)?

Have you been diagnosed with COVID-19?

If yes, have you been retested?

Are you having shortness of breath or other difficulties breathing?

Do you have a cough?

Do you have any other flu-like symptoms, such as gastrointestinal upset,
headache or fatigue?

Have you experienced recent loss of taste or smell?

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

Positive responses to any of these would likely indicate a deeper discussion with the dentist before
proceeding with elective dental treatment.

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