Supplemental Health Questionnaire

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:
Patient First Name:
Last Name:
Parent/Guardian First Name:
Last Name:
Relationship to Patient:
Have you, your child, others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease?
Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances traveled outside the state within the past 14 days?
Do you, your child, others accompanying you to today's appointment or other recent acquaintances have:
A Fever? (defined as above 100.4° F degrees)
A Cough?
Shortness of Breath and/or Trouble Breathing?
Persistent Pain, Pressure or Tightness in the Chest?
A Loss of Taste or Smell?
I understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s orthodontic appointment.
Patient/Parent/Guardian Signature:
Date: