7110 Highland Road, White Lake, MI 48383

(248) 887-8387
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Dentist in White Lake MI
David J. Campbell DDS
7110 Highland Road
White Lake, MI 48383
(248) 887-8387
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PATIENT SCREENING FORM

Patient Name:

 

PRE-APPOINTMENT

IN-OFFICE

 

Date:

 

Date:

 

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

 

___Yes

 

   ___ No

 

 

___Yes

 

___No

 

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

___Yes

 

   ___ No

 

 

___Yes

 

   ___ No

 

 

Do you/they have a cough?

___Yes

 

   ___ No

 

 

___Yes

 

   ___ No

 

 

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

___Yes

 

   ___ No

 

 

___Yes

 

   ___ No

 

 

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

___Yes

 

   ___ No

 

 

___Yes

 

   ___ No

 

 

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.

 

___Yes

 

   ___ No

 

 

___Yes

 

   ___ No

 

 

Is your/their age over 60?

___Yes

 

   ___ No

 

 

___Yes

 

   ___ No

 

 

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

___Yes

 

   ___ No

 

 

___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

 

 

___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.