Health Questionnaire Form

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:

    Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease?

    Do you, your child, or others accompanying you to today’s appointment or other recent acquaintances have:

    - A Fever (defined as above 99.6 degrees) YesNo

    - A Cough? YesNo

    - Shortness of Breath and/or Trouble Breathing? YesNo

    - Persistent Pain, Pressure, or Tightness in the Chest? YesNo

    - Any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue? YesNo

    - Have you/they experienced a recent loss of taste or smell?

    - Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

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