COVID Supplemental Health Questionnaire

Pediatric Dentistry Treatment in the Era of COVID-19


If you have been exposed to a communicable disease, you may spread the disease to the pediatric dentist, pediatric dentistry 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)?
Chills?
Cough?
Sore Throat?
Shortness of breath and/or trouble breathing?
Persistent pain, pressure or tightness in the chest?
New loss of taste or smell?

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?

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?
If yes provide approximate dates of illness through

I understand that if the answer to any of these questions is yes, I may be asked to reschedule today’s pediatric dentistry appointment to a later date.
Patient First Name:
MI:
Last Name:
Parent/Guardian First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Patient/Parent/Guardian Signature:
Date: