Patient Screening Form Print Form

Use this form to screen patients before their appointment and when they arrive for their appointment.

Staff screener

Patient Name

Patient age

Who answered

Patient

Other (specify)

Contact Method

Phone

Other

Identify yourself and explain the purpose of the call, which is to determine whether there are any special considerations for their dental appointment. Have the patient answer the following questions.

Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

Pre-Screen
Yes No

In-Office
Yes No

Do you have any of the following symptoms

• Fever
• New onset of cough
• Worsening chronic cough
• Shortness of breath
• Difficulty breathing
• Sore throat
• Difficulty swallowing
• Decrease or loss of sense of taste or smell
• Chills
• Headaches
• Unexplained fatigue/malaise/muscle aches (myalgias)
• Nausea/vomiting, diarrhea, abdominal pain
• Pink eye (conjunctivitis)
• Runny nose/nasal congestion without other known cause

Pre-Screen
Yes No

In-Office
Yes No

If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

Pre-Screen
Yes No

In-Office
Yes No