Dothan Dentist

COVID-19 Patient Screening

COVID-19 Patient Screening Form

Patient Name:
Phone Number:
Email Address:
Pre-Appointment In-Office
Date: Date:
Do you have a fever or have you/they felt hot or feverish recently (14-21 days)?
Yes No
Yes      No
Are you having shortness of breath or other difficulties breathing?
Yes No
Yes      No
Do you 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 experienced recent loss of taste or smell?
Yes No
Yes      No
Are you in contact with any confirmed COVID-19 positive person?
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
Have you been tested for Covid-19?
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?

Please enter code above in the field below.