Bellevue Impressions Dentistry - COVID-19 Screening Form

COVID-19 Screening Form
Patient Name *

First Name Last Name
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

Yes No
Are you/they having shortness of breath or other difficulties breathing?

Yes No
Do you/they have a cough?

Yes No
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes No
Have you/they experienced recent loss of taste or smell?

Yes No
Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Yes No
Is your/their age over 60?

Yes No
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Yes No
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

Yes No
Positive responses to any of these would likely indicate a 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 area’s information.
Should be Empty: