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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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: Δ
