COVID-19 Questionnaire COVID-19 Questionnaire Do you or the patient have a fever or have felt hot or feverish within the last 14-21 days?(Required) Yes No Do you or the patient have shortness of breath or other difficulties breathing?(Required) Yes No Do you or the patient have a cough?(Required) Yes No Do you or the patient have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?(Required) Yes No Have you or the patient experienced recent loss of taste or smell?(Required) Yes No Have you or the patient been in contact with any confirmed COVID-19 positive patients?(Required) Yes No Do you or the patient have heart disease, lung disease, kidney disease, diabetes, or any autoimmune disorders?(Required) Yes No Have you or the patient traveled in the past 14 days to any regions affected by COVID-19?(Required) Yes No 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.
