Patient name
Date

Screening questions

Date:

Staff initial:

Notes

Do you have a fever or above-normal temperature (>100.4° F)? Take temperature at appointment
[radio* temperature "No" "Yes"]
Are you experiencing shortness of breath or having trouble breathing?
[radio* having-trouble-breathing "No" "Yes"]
Do you have a dry cough?
[radio* dry-cough "No" "Yes"]
Do you have a runny nose?
[radio* runny-nose "No" "Yes"]
Have you recently lost or had a reduction in your sense of smell or taste?
[radio* lost-of-smell "No" "Yes"]
Do you have a sore throat?
[radio* sore-throat "No" "Yes"]
Are you experiencing chills or repeated shaking with chills?
[radio* chills "No" "Yes"]
Do you have unexplained muscle pain?
[radio* muscle-pain "No" "Yes"]
Do you have a headache?
[radio* headache "No" "Yes"]
Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?
[radio* last-14-days "No" "Yes"]
Have you been in unprotected contact with someone who has tested positive for COVID-19 in the last 14 days? “Unprotected contact” means without the use of personal protective equipment.
[radio* contact-last-14-days "No" "Yes"]
Have you been tested for COVID-19 in the last 14 days? If “no,” proceed to next question.
[radio* been-tested "No" "Yes"]
If yes, what is the result of the testing?

If negative, proceed to next question.

If still waiting on results, schedule appointment after results are known.
[radio* testing-results "No" "Unsure" "Positive"]
Have you traveled more than 100 miles from your home in the last 14 days?
[radio* traveled-100-miles "No" "Yes"]

Patient signature required at appointment:

I agree to notify the dental practice if within 2 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 2 days.Acepto dar aviso a la clínica dental si dentro de dos días presento síntomas de COVID-19 o tengo un resultado positivo de COVID-19. Entiendo que la clínica dental tiene la obligación legal y ética de informarme si un miembro del personal con el que tuve contacto ha tenido un resultado positivo de COVID-19 dentro de dos días.

Signature
Date