Patient/Parent Name

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

Yes No

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

Yes No

Do you/they have a cough? *

Yes No

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

Yes No

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

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

Is your/their age over 60? *

Yes No

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

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

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

Yes No

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

Yes No

Do you/they have a cough?

Yes No

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

Yes No

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

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

Is your/their age over 60?

Yes No

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

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

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.

Signature *

Clear

Date *

Dr. Todd J. Ayars, DDS PA COVID-19 Screening Form

Pre-Appointment

In-Office (to be completed on day of appointment)