COVID-19 Patient Screening Form
Patient Name:
Phone Number:
Email Address:
Pre-Appointment In-Office
Date: Date:
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Yes No
Yes      No
Are you/they having shortness of breath or other difficulties breathing?
Yes No
Yes      No
Do you/they have a cough?
Yes No
Yes      No
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Yes No
Yes      No
Have you/they experienced recent loss of taste or smell?
Yes No
Yes      No
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 tretment.
Yes No
Yes      No
Is your/their age over 60?
Yes No
Yes      No
Do you/they have heart disease, lung disease, kidney disease,diabetes or any auto-immune disorders?
Yes No
Yes      No
Have you/they traveled in the past 14 days to any regions affected by COVID19? (as relevant to your location)
Yes No
Yes      No

Positive responses to any of these would likely indicate a deeper discussion with the dentist before with elective dental treatment.

For testing, see the list of state and Territorial Health Department Websites for your specific area's information.

Medical History Update:
Have you seen a Doctor since your last visit?
Have you been diagnosed with anything new?
Have you had any surgeries since your last visit?
Are you taking any new medications since your last visit?
Please list all medicines, including any over-the-counter, vitamins and/or supplements.
Do you have any dental concerns at this time? Broken tooth? Tooth ache?

dental dental dental
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Office Hours:

  • Monday 7:00am - 4:00pm
  • Tuesday 7:00am - 3:00pm
  • Wednesday 7:00am - 4:00pm
  • Thursday 7:00am - 1:00pm
  • Friday Dr T teaches at the U. of W. School of Dentistry

Wheel Chair Accessible

(360) 943-4420

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