Patient Screening Form

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333 Circle Avenue, Forest Park, IL 60130

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First Name

Last Name

IN-OFFICE DATE

PRE-APPOINTMENT DATE

Do you/they have a fever or have you/they felt hot or feverish recently (14-21 days)

Yes

Are you/they having shortness of breath or other difficulties breathing?

Yes

Do you/they have a cough?

Yes

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

Yes

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

Yes

Are you/they in contact with any confirmed COVID-19 positive patients?

Yes

(Patients who are well but who have a sick family member of home with COVID-19 should consider postponing elective treatment.)

Is your/their age over 60?

Yes

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Yes

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

Yes

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

For testing see the list of State and territorial Health Department Websites for your specific are's information.

Thanks for submitting!

333 Circle Avenue, Forest Park, IL 60130

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