1. Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
YesNo
2. Are you/they having shortness of breath or other difficulties breathing?
YesNo
3. Do you/they have a cough?
YesNo
4. Any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
YesNo
5. Have you/they experienced recent loss of taste or smell?
YesNo
6. 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.
YesNo
7. Is your/their age over 60?
YesNo
8. Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
YesNo
9. Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
YesNo

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.