Supplemental Health Questionnaire
Orthodontic Treatment in the Era of COVID-19
If you have been exposed to a communicable disease, you may spread the disease to the orthodontist, orthodontic staff, or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:
Do you, your child, others accompanying you to today's appointment or anyone you have recently been in contact with have any of the following symptoms?
Fever (defined as above 100.4° F degrees)?
Yes
No
Chills?
Yes
No
Cough?
Yes
No
Sore Throat?
Yes
No
Shortness of breath and/or trouble breathing?
Yes
No
Persistent pain, pressure or tightness in the chest?
Yes
No
New loss of taste or smell?
Yes
No
Have you or others accompanying you to today’s appointment traveled outside of our local area or outside of the US within the past 14 days?
Yes
No
If yes provide travel location
Have you, your child, others accompanying you to today’s appointment or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease?
Yes
No
If yes provide approximate dates of illness
through
Has the patient been advised to self-quarantine because of exposure to someone with SARS-CoV-2 infection?
Yes
No
Will you notify our office if you or your child (the patient) develops signs or symptoms or are diagnosed with COVID-19 within 2 days following your appointment?
Yes
No
I understand that if the answer to any of these questions is yes, I may be asked to reschedule today’s orthodontic appointment to a later date.
Patient First Name:
MI:
Last Name:
Parent/Guardian First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Patient/Parent/Guardian Signature:
Date: