COVID-19 Patient Pre-Screening Form Must be submitted within 7 days to 24 hours prior to your dental appointment. Name:* Temp:* Date of Pre-Appointment Screening:* MM slash DD slash YYYY Screened by: HiddenIn-Office Date: MM slash DD slash YYYY Person Responsible for Account:Name: Relationship to patient: Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 1. Do you have fever or have you felt hot or feverish recently (14-21 days)?PRE-APPOINTMENT* Yes No HiddenIN-OFFICE Yes No 2. Are you having shortness of breath or other difficulties breathing? PRE-APPOINTMENT* Yes No HiddenIN-OFFICE Yes No 3. Do you have a cough?PRE-APPOINTMENT* Yes No Allergies: HiddenIN-OFFICE Yes No 4. Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?PRE-APPOINTMENT* Yes No List Symptoms HiddenIN-OFFICE Yes No 5. Have you experienced recent loss of taste or smell?PRE-APPOINTMENT* Yes No HiddenIN-OFFICE Yes No 6. Have you been in contact with any confirmed COVID-19 Positive patients?PRE-APPOINTMENT* Yes No Date of contact: Were you tested? Yes No Type of Covid Test Swab / Antibody: Results of Covid Test + / - HiddenIN-OFFICE Yes No Date of contact: Were you tested? Yes No Type of Covid Test Swab / Antibody: Results of Covid Test + / - 7. Are you over the age over 60?PRE-APPOINTMENT* Yes No HiddenIN-OFFICE Yes No 8. Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?PRE-APPOINTMENT* Yes No If yes: HiddenIN-OFFICE Yes No If yes: 9. Have you traveled out of Santa Clara County in the past 14 days? PRE-APPOINTMENT* Yes No Where? HiddenIN-OFFICE Yes No Where? Email: Signature (Patient/Parent/Guardian):*The signer must be 18 years or older.Children under 18 need a parent signature. If under 18, please print name & relationship below:Name: Relationship with patient: CAPTCHA
