Matix - ADA COVID19 Screening

Patient Screening Form
Date

Month Day Year
Date
Patient Name *

First Name Middle Name Last Name
Have you been vaccinated?

Yes No
If so, please provide the date you were fully vaccinated.

Month Day Year
Date
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?

Yes No
Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective treatment.
- For testing, see the list of State and Territorial Health Department Websites for your specific area's information.
Please verify that you are human *
Should be Empty:

Patient Screening Form