Supplemental Health Questionnaire COVID-19

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Supplemental Health Questionnaire COVID-19

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)?YesNo

Cough?YesNo

Shortness of breath and/or trouble breathing?YesNo

Persistent pain, pressure or tightness in the chest?YesNo

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?YesNo

If yes, provide approximate dates of illness

From

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:

Middle Initial:

Last Name:

Date:

Patient/Parent/Guardian Signature: