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SUPPLEMENTAL
HEALTH QUESTIONNAIRE
Orthodontic Treatment in the Era of COVID-19
If you have been exposed to a communicable disease, you may spread the disease to the orthodontist, orthodontic staff, or other patients/parents 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?
Fever (defined as above 100.4 degrees)?
Yes
No
Cough?
Yes
No
Shortness of breath and/or trouble breathing?
Yes
No
Persistent pain, pressure, or tightness in the chest?
Yes
No
Have you, your child, others accompanying you to today’s appointment or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID-19 or any other communicable disease?
Yes
No
If yes provide approximate dates of illness
Consent
I understand that if the answer to any of these questions is yes, I may be asked to reschedule today’s orthodontic appointment to a later date.
Patient/Parent’s Name
First
Last
Email
Patient/Parent’s Signature
Date
Date Format: MM slash DD slash YYYY
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