SUPPLEMENTAL HEALTH QUESTIONNAIRE
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:
Do you, your child, others accompanying you to today’s appointment or anyone you have recently been in contact with have any of the following symptoms?
Patient's First Name
Patient's Last Name
Fever (defined as above 99.6 degrees)?
No
Yes
New Loss of taste and/or smell?
No
Yes
Cough?
No
Yes
Shortness of breath and/or trouble breathing?
No
Yes
Persistent pain, pressure, or tightness in the chest?
No
Yes
Sore Throat?
No
Yes
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?
No
Yes
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?
No
Yes
If yes, Where?
By signing this form, I understand that if the answer to any of these questions is yes, I may be asked to reschedule today’s orthodontic appointment to a later date.
PATIENT/GUARDIAN SIGNATURE
date
RELATIONSHIP TO PATIENT
or
If you choose to print, be sure to bring the printed form with you on your first visit.
