Covid-19 Questionnaire - Olson Orthodontics

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ADA COVID-19 Questionnaire

PATIENT Name *

First

Last

Date / Time *

Date

Time

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

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

Do you / they have a cough? *

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

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

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.

Is your / their age over 60? *

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

Have you / they travelled in the past 14 days to any regions affected by COVID-19? *

(as relevant to your location)

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