Patient Screening Form | Princeton Periodontics and Implants

Patient Name *

First

Last

Temp:

Pre-Appointment Date

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

Yes
No

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

Yes
No

Do you/they have a cough?

Yes
No

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

Yes
No

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

Yes
No

Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but have a sick family member at home with COVID-19 should consider postponing elective treatment.

Yes
No

Is your/they age over 60?

Yes
No

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

Yes
No

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

Yes
No

In-Office Questions

In-Office Date