CDA Covid-19 Patient Screening Form

Instructions for use: Use one form for each patient appointment. Ask the patient these questions at the time appointment is made or with an appointment reminder, and again no more than two days before the appointment.

Patient Name

First Last

Parent/Guardian Name

First Last

Screening Questions

1. Are you fully vaccinated for COVID-19?

Yes
No

An individual is considered fully vaccinated if it has been more than 2 weeks since they received the last shot of a 2-dose vaccine (for example, Moderna or Pfizer) or a single dose vaccine (J&J). If the answer is yes, screen for symptoms only and not for close contact, COVID-19 testing, or travel. Observational screening, instead of questioning the patient about symptoms or having the patient complete a form, should be noted in the patient chart.

2. Do you have a fever or above normal temperature (>100.0˚ F)? (Take temperature at appointment)

Yes
No

If the patient answers “yes,” note the symptoms reported and seek additional information from the patient about the possible causes. If the patient does not need emergency care, consider not scheduling or seeing the patient until symptoms resolve.

3. Are you experiencing more than one of the following symptoms: shortness of breath, dry cough, sore throat, unexplained muscle pain, headache or nausea, new loss or taste or smell?

Yes
No

If the patient answers “yes,” note the symptoms reported and seek additional information from the patient about the possible cause. If the patient does not need emergency care, consider not scheduling or seeing the patient until symptoms resolve.

4. Even if you don’t currently have any of the above symptoms, have you experienced more than one of these symptoms in the last 14 days?

Yes
No

If “yes” and the patient does not need emergency care, do not see the patient unless it has been more than 10 days since symptoms first appeared and 24 hours of no fever without the use of fever-reducing medication.

5. Have you been advised to quarantine due to close contact with someone diagnosed with COVID-19?

Yes
No

If yes, ask when the quarantine period ends and set appointment time after that date.

6. Have you been tested for COVID-19 in the last 14 days?

Yes
No

What is the result of the testing?

Positive
Negative
Still waiting on results

If still waiting on results, schedule an appointment after results are known.

If positive, determine if patient needs emergency care. If not an emergency, schedule the patient to be seen when it has been more than 10 days (20 days if the patient's illness was severe) since symptoms first appeared and 24 hours of no fever without the use of fever-reducing medication.

7. Have you traveled out of state or out of country in the last 14 days?

Yes
No

Fully vaccinated individuals need not quarantine, according to the CDC. Know your county’s health officer orders with regard to non-essential travel by individuals not vaccinated for COVID-19. The county orders will have quarantine recommendations.

Patient signature required at appointment

I agree to notify the dental practice if within 2 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff person I had close contact with tested positive for COVID-19 within 2 days

Signature*

Name

This field is for validation purposes and should be left unchanged.