Fillable 3 ADA Patient Screening Form

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3 ADA Patient Screening Form

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Patient Screening Form
Patient Name:
PRE-APPOINTMENT
IN-OFFICE
Date:
Date:
Do you/they have fever or have you/they felt hot or feverish recently
(14-21 days)?
Yes No
Yes No
Are you/they having shortness of breath or other difficulties breathing?
Yes No
Yes No
Do you/they have a cough?
Yes No
Yes No
Any other flu-like symptoms, such as gastrointestinal upset, headache
or fatigue?
Yes No
Yes No
Have you/they experienced recent loss of taste or smell?
Yes No
Yes No
Are you/they 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.
Yes No
Yes No
Is your/their age over 60?
Yes No
Yes No
Do you/they have heart disease, lung disease, kidney disease,
diabetes or any auto-immune disorders?
Yes No
Yes No
Have you/they traveled in the past 14 days to any regions affected
by COVID-19? (as relevant to your location)
Yes No
Yes No
Pos
itive responses to any of these would likely indicate a deeper discussion with the dentist before
proceeding with elective dental treatment.
• For testing, see the list of State and Territorial Health Department Websites for your specific area’s information.
Courtesy!of! the! American! Dental! Association!(ADA®)! 2020!
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3 ADA Patient Screening Form

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Completed 24 December 2020

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