Dentist Sacramento Covid-19 Screening Form

Covid-19 Patient Screening Form

Instructions for use: Use one form for each patient appointment. Ask the patient these questions at the time appointment is made or with appointment reminder, and again no more than two days before the appointment. Take the patient’s temperature and note any signs of fever, coughing, or shortness of breath. 

 

Patient/Parent/Guardian Names: _____________________________________________

 

Screening Questions

Date: ________

Staff Initial: ___

Date: ________

Staff Initial: ___

Notes

Do you have a fever or above-normal temperature (>100.4°F)? Take temperature at appointment.

☐ Yes


☐ No

☐ Yes


☐ No

If patient answers “yes” to either question on shortness of breath or coughing, or answers yes to any combination of two other symptoms and the patient does not need emergency care, consider not scheduling or seeing the patient until symptoms resolve or until patient can provide proof they are not infectious for COVID-19. The dentist may want to seek additional information from the patient regarding symptoms.

Are you experiencing shortness of breath or having trouble breathing?

☐ Yes


☐ No

☐ Yes


☐ No

Do you have a dry cough?

☐ Yes


☐ No

☐ Yes


☐ No

Do you have a runny nose?

☐ Yes


☐ No

☐ Yes


☐ No

Have you recently lost or had a reduction in your sense of smell or taste?

☐ Yes


☐ No

☐ Yes


☐ No

Do you have a sore throat?

☐ Yes


☐ No

☐ Yes


☐ No

Are you experiencing chills or repeated shaking with chills?

☐ Yes


☐ No

☐ Yes


☐ No

Do you have unexplained muscle pain?

☐ Yes


☐ No

☐ Yes


☐ No

Do you have a headache?

☐ Yes


☐ No

☐ Yes


☐ No

Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?

☐ Yes


☐ No

☐ Yes


☐ No

If “yes” and patient does not need emergency care, do not see patient unless it has been more than 7 days since symptoms first appeared and 3 days of no fever without use of fever-reducing medication.

Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?

☐ Yes


☐ No

☐ Yes


☐ No

If yes, ask for date of last contact with COVID-positive patient and set appointment time for more than 14 days later, unless the patient needs emergency care.

Have you been tested for COVID-19 in the last 14 days? If “no”, proceed to the next question.

☐ Yes


☐ No

☐ Yes


☐ No

  

      If yes, what is the result of the testing?


      If negative,  proceed to the next question.


      If still waiting for results, schedule an appointment after results are known.

☐ Yes


☐ Unsure


☐ No

☐ Yes


☐ Unsure


☐ No

If positive, determine if patient needs emergency care. If not an emergency, schedule patient to be seen when it has been more than 7 days since symptoms first appeared and 3 days of no fever without use of fever-reducing medication.

Have you traveled more than 100 miles from your home in the last 14 days?

☐ Yes


☐ No

☐ Yes


☐ No

If yes, determine if patient traveled to an area where COVID-19 cases are high. Determine if patient followed physical distancing precautions and wore a mask while in public. Use professional judgement when determining whether to proceed with the appointment.

 

Patient signature required at appointment:

I agree to notify the dental practice if within 14 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had contact with tested positive for COVID-19 within 14 days. 

 

Signature: _________________________________ Date: _____________