In-Office Patient Screening Form Patient Name* Question Answer Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? YESNO Are you/they having shortness of breath or other difficulties breathing? YESNO Do you/they have a cough? YESNO Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? YESNO Have you/they experienced recent loss of taste or smell? YESNO 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.) YESNO Is your/their age over 60? YESNO Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? YESNO Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) YESNO Sign Below. This will serve as my electronic signature for the Patient Screening Form. 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.