RIVER WALK DENTAL

ADA PATIENT SCREENING FORM

Name
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
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Are you/they having shortness of breath or other difficulties breathing?
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Do you/they have a cough?
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Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
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Have you/they experienced recent loss of taste or smell?
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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.
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Is your/their age over 60?
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Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
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Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
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Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

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