Covid-19 Patient Screening Form

Instructions for use: Use one form for each patient appointment. Ask the patient these questions at the time appointment is made or with appointment reminder, and again no more than two days before the appointment. Take the patient’s temperature and note any signs of fever, coughing, or shortness of breath.

Patient/Parent/Guardian Information:

Last Name:

Middle Name:

First Name:

Date of Birth:

Phone

E‐mail

Screening questions	Date: Date: Staff initial: Staff initial:	Date: Date: Staff initial: Staff initial:	Notes
Do you have a fever or above-normal temperature (>100.4° F)? Take temperature at appointment.	No Yes	No Yes	If patient answers "yes" to either question on shortness of breath or coughing, or answers yes to any combination of two other symptoms and the patient does not need emergency care, consider not scheduling or seeing the patient until symptoms resolve or until patient can provide proof they are not infectious for COVID-19. The dentist may want to seek additional information from the patient regarding symptoms.
Are you experiencing shortness of breath or having trouble breathing?	No Yes	No Yes
Do you have a dry cough?	No Yes	No Yes
Do you have a runny nose?	No Yes	No Yes
Have you recently lost or had a reduction in your sense of smell or taste?	No Yes	No Yes
Do you have a sore throat?	No Yes	No Yes
Are you experiencing chills or repeated shaking with chills?	No Yes	No Yes
Do you have unexplained muscle pain?	No Yes	No Yes
Do you have a headache?	No Yes	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?	No Yes	No Yes	If "yes" and patient does not need emergency care, do not see patient unless it has been more than 7 days since symptoms first appeared and 3 days of no fever without use of fever-reducing medication.
Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?	No Yes	No Yes	If yes, ask for date of last contact with COVID-positive patient and set appointment time for more than 14 days later, unless the patient needs emergency care.
Have you been tested for COVID-19 in the last 14 days? If "no," proceed to next question.	No Yes	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.	No Unsure Positive	No Unsure Positive	If positive, determine if patient needs emergency care. If not an emergency, schedule patient to be seen when it has been more than 7 days since symptoms first appeared and 3 days of no fever without use of fever-reducing medication.
Have you traveled more than 100 miles from your home in the last 14 days?	No Yes	No Yes	If yes, determine if patient traveled to an area where COVID-19 cases are high. Determine if patient followed physical distancing precautions and wore a mask while in public.Use professional judgement when determining whether to proceed with the appointment.

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.

Signature:

Use your mouse cursor or the tip of your finger to sign above