COVID 19 Treatment Screening

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    Based on CDC recommendation and from the CDC website:

    “The patient should be asked about the presence of symptoms of a respiratory infection and history of travel to areas experiencing transmission of COVID-19 or contact with possible patients with COVID-19. If the patient is afebrile (temperature < 100.4˚F) and otherwise without symptoms consistent with COVID-19, then emergency dental care may be provided using appropriate engineering controls, work practices, and infection control practices.”

    Your Name
    Today’s Date

    YesNo

    YesNo

    YesNo

    Cough YesNo
    Shortness of breath YesNo
    Body ache YesNo
    Fever YesNo
    Runny Nose YesNo
    Trouble breathing YesNo
    Persistent pain or pressure in the chest YesNo
    Your Temperature today :
    taken by :
    I certify that the above information given to my health care provider is accurate and true.
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