ADA

American Dental Association

America's leading advocate for oral health

Patient Screening Form

Enter Patient Name*

PRE-APPOINTMENT

IN-OFFICE

1. Do you/the patient have fever or have you/the patient felt hot or feverish recently (14–21 days) ?

PRE-APPOINTMENT

Yes

IN-OFFICE

Yes

2. Are you/the patient having shortness of breath or other difficulties breathing ?

PRE-APPOINTMENT

Yes

IN-OFFICE

Yes

3. Do you/the patient have a cough ?

PRE-APPOINTMENT

Yes

IN-OFFICE

Yes

4. Any other flu-like symptoms, such as gastrointestinal upset,headache or fatigue ?

PRE-APPOINTMENT

Yes

IN-OFFICE

Yes

5. Have you/the patient experienced recent loss of taste or smell ?

PRE-APPOINTMENT

Yes

IN-OFFICE

Yes

6. Are you/the patient in contact with any confirmed COVID-19 positive patients ?

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment .

PRE-APPOINTMENT

Yes

IN-OFFICE

Yes

7. Is your/the patient’s age over 60 ?

PRE-APPOINTMENT

Yes

IN-OFFICE

Yes

8. Do you/the patient have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders ?

PRE-APPOINTMENT

Yes

IN-OFFICE

Yes

9. Have you/the patient traveled in the past 14 days ?

PRE-APPOINTMENT

Yes

IN-OFFICE

Yes

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment .

For testing, see the Centers for Disease Control and Prevention (CDC)’s list of State and Territorial Health Department Websites for your specific area’s information: https://www.cdc.gov/ publichealthgateway/healthdirectories /healthdepartments.html.