Ada Screening Form ADA Patient Screening Form First Name Last Name Email Address Phone Number Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)? YesNo Are you/they having shortness of breath or other difficulties breathing? YesNo Do you/they have a cough? YesNo Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? YesNo Have you/they experienced recent loss of taste or smell? YesNo 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 Is your/their age over 60? YesNo Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? YesNo 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. Thank you! Your submission has been received! Oops! Something went wrong while submitting the form.