Supplemental Health Questionnaire Form
Required fields
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
Patient last Name
Fever (defined as above 99.6 degrees)?
Yes
No
New loss of taste and/or smell?
Yes
No
Cough?
Yes
No
Shortness of breath and/or trouble breathing?
Yes
No
Persistent pain, pressure, or tightness in the chest?
Yes
No
Sore throat?
Yes
No
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?
Yes
No
If yes provide approximate dates of illness:
Have you or others here today traveled outside of the local area/outside the us within the past 2 weeks?
Yes
No
If yes, where?
Patient/Guardian Signature
Date
Relationship to Patient
Submit
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