Form: ADA COVID Patient Screening Form

Patient Information

Do you have a fever or have you felt hot or feverish recently (14-21 days)?
Are you having shortness of breath or other difficulties breathing?
Do you have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you experienced recent loss of taste or smell?
Have you been in contact with any confirmed COVID-19 positive patients, persons who are well but who have a sick family member at home with COVID-19 or in contact with anyone suspected of having COVID-19?
Are you over the age of 60?
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
If I should develop any of the above symptoms in the next 14 days following my dental visit, I will notify the office.

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment and may need to be rescheduled.

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

Sign Form

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.