SUPPLEMENTAL HEALTH QUESTIONNAIRE COVID-19

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Note: The fields indicated with an asterisk * are required fields.

SUPPLEMENTAL HEALTH QUESTIONNAIRE
COVID-19

If you have been exposed to a communicable disease, you may spread the disease to the orthodontist, orthodontist staff, or other patients/parents/family members in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:

Do you, your child, others accompanying you to today’s appointment or anyone you have recently been in contact with have any of the following symptoms/conditions?

Fever (defined as above 100.4o F degrees) in the last 21 days *

Yes

Shortness of breath and/or trouble breathing *

Yes

Cough *

Yes

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

Yes

Experienced recent loss of taste or smell *

Yes

In contact with any confirmed COVID-19 positive patients *

Yes

Age over 60 *

Yes

Have heart disease, lung disease, kidney disease, diabetes or any autoimmune disorders *

Yes

Traveled in the past 14 days to a region highly affected by COVID-19 *

Yes

I understand that a positive response to any of these would likely result in a deeper discussion before proceeding with elective dental treatment and I may be asked to reschedule the orthodontic appointment to a later date.

Patient Name *

Email *

Parent/Legal Guardian Name (if applicable)

Patient/Parent/Legal Guardian Signature

Signer Name

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Main/Brickell Office: 175 SW 7th St, Suite 1408 Miami FL 33130
Key Biscayne: 260 Crandon Blvd, Suite 31 Key Biscayne FL 33149
Tel. 305 - 373 - 7799
info@deroodeortho.com

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