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Date*

PREAPPOINTMENT CHECK

1. Have you previously been diagnosed with COVID-19, or do you think you've had/have COVID-19? (If no, skip to question 5)*

Yes
No

2. If YES, when and how were you confirmed positive?

I think I had it
I had a positive nasal swab test
I had a positive blood test
I had a positive saliva test
I currently have symptoms and are waiting for a test

3. If you have had COVID-19, how were you confirmed negative?

I was diagnosed negative by a nasal swab test
I show antibodies to COVID-19 with a blood test
My doctor said I no longer have it because I don't have any symptoms
I don't have any symptoms, so I don't have it

4. If you have COVID-19, when were you confirmed negative?

24 hours ago
Today
10 days after testing

5. Do you currently have (or have you experienced) any of the following symptoms in the past 21 days?

Fever

Yes
No

Fatigue (Feeling tired)

Yes
No

Altered or loss of taste/smell

Yes
No

Dry cough

Yes
No

Trouble breathing

Yes
No

Shortness of breath, difficulty breathing, chest tightness

Yes
No

Confusion

Yes
No

Bluish lips or face

Yes
No

Chills/repeated shaking with chills

Yes
No

Muscle pain

Yes
No

Headache or sore throat

Yes
No

Any other flu-like symptoms

Yes
No

GI upset or diarrhea

Yes
No

6. Are you in contact with anyone who has been sick and/or confirmed to be COVID-19 positive?

Yes
No

7. In the past 14 days have you traveled to any regions affected by COVID-19?

Yes
No

Some medical conditions have been associated with more sever COVID-19 disease. The Following questions are an attempt to determine your risk:

8. Are you over age 65?

Yes
No

9. Do you have high blood pressure?

Yes
No

Is it controlled?

Yes
No

10. Do you have diabetes?

Yes
No

11. Are you overweight?

Yes
No
No Answer

12. Do you have respiratory problems?

Yes
No

13. Do you have autoimmune disorders?

Yes
No

14. Are there any other conditions you would like to report?

Yes
No

Conditions

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

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General Covid-19 Screening Questionnaire

PREAPPOINTMENT CHECK

5. Do you currently have (or have you experienced) any of the following symptoms in the past 21 days?

Some medical conditions have been associated with more sever COVID-19 disease. The Following questions are an attempt to determine your risk: