Patient Screening - Cochran & Soares Pediatric Dentistry

Patient Screening Form

Patient Name*

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

Pre-Appointment*

Yes
No

In-Office

Yes
No

Do you/they having shortness of breath or other difficulties breathing?

Pre-Appointment*

Yes
No

In-Office

Yes
No

Do you/they have a cough?

Pre-Appointment*

Yes
No

In-Office

Yes
No

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

Pre-Appointment*

Yes
No

In-Office

Yes
No

Have you/they experienced recent loss of taste or smell?

Pre-Appointment*

Yes
No

In-Office

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

Pre-Appointment*

Yes
No

In-Office

Yes
No

Is your/their age over 60?

Pre-Appointment*

Yes
No

In-Office

Yes
No

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Pre-Appointment*

Yes
No

In-Office

Yes
No

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

Pre-Appointment*

Yes
No

In-Office

Yes
No

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 list of State and Territorial Health Department Websites for your specific area’s information.

Name of Parent or Guardian*

Email Address*

Name

This field is for validation purposes and should be left unchanged.