Rodo - Patient Screening Form

Health History Form

Patient Name:*

First Last

Date of Birth:*

Date*

Email*

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

Yes
No

Mode of Appointment:

Are you/they having shortness of breath or other difficulties breathing?

Yes
No

Mode of Appointment:

DO you/they have a cough?

Yes
No

Mode of Appointment:

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

Yes
No

Mode of Appointment:

Have you/they experienced recent loss of taste or smell?

Yes
No

Mode of Appointment:

Are you/they in contact with any confirmed COVID-19 positive patients?

Yes
No

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Mode of Appointment:

Is your /their age over 60?

Yes
No

Mode of Appointment:

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Yes
No

Mode of Appointment:

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)

Yes
No

Mode of Appointment:

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.