Covid 19 Prescreening ADA COVID-19 Patient Screening Form Patient Name * Select * Pre-appointmentScreening Date * Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? * Yes No Are you/they having shortness of breath or other difficulties breathing? * Yes No Do you/they have a cough? * Yes No Any other flul-like symptoms, such as gastrointestinal upset, headache or fatigue? * Yes No Have you/they experienced recent loss of taste or smell? * Yes No Are you/they in contact with any confirmed COVID-19 positive patients? * Yes No Patiens who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment. Is your/their age over 60? * Yes No Do you/they have heart disease, luing disease, kidney disease, diabetes or any auto-immune disorders? * Yes No Have you/they traveled in the past 14 days to any regions affected by COVID-19? * Yes No (as relevent to your location) reCAPTCHA If you are human, leave this field blank. Submit Δ Download PDF
