Skip to main content

Covid 19 Prescreening ADA

COVID-19 Patient Screening Form
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? *
Are you/they having shortness of breath or other difficulties breathing? *
Do you/they have a cough? *
Any other flul-like symptoms, such as gastrointestinal upset, headache or fatigue? *
Have you/they experienced recent loss of taste or smell? *
Are you/they in contact with any confirmed COVID-19 positive patients? *
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? *
Do you/they have heart disease, luing disease, kidney disease, diabetes or any auto-immune disorders? *
Have you/they traveled in the past 14 days to any regions affected by COVID-19? *
(as relevent to your location)

Download PDF