PATIENT QUESTIONNAIRE: PATIENT
you traveled by airplane in the last 3 weeks? _____________________________
you been in contact with anyone who was sick? ___________________________
you attended any large group functions? _________________________________
you had any of the following symptoms within the last two weeks: fever,
fatigue, dry cough, altered taste, altered smell, trouble breathing, productive
cough (mucous in cough), or muscle pain?
you previously had the SARS-COV-2 Virus (novel coronavirus)? If so, did you
test positive and what test were you administered?
you over the age of 65 and/or have pre-existing health conditions related to
the following: diabetes, chronic lung disease or asthma, serious heart
condition, immunocompromised, or chronic kidney or liver disease?
Family Dental is following over and above CDC, ADA and NJDA recommendations for
is an acknowledgement that even with following all these guidelines, there is
still a risk with treatment due to aerosols and close contact.
has the right not to treat due to your answers and within his professional
opinion that you may be a higher risk patient.
I agree to
be treated knowing all the above.
Guardian) Signature Date