COVID-19 PATIENT QUESTIONNAIRE



COVID‐19 DENTAL TREATMENT NOTICE/ACKNOWLEDGEMENT OF RISK, POST-OP INSTRUCTIONSThe COVID‐19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. Our goal is to provide a safe environment for our patients and team, and to advance the safety of our local community. To that end, we want you to be aware of the additional risks of possibly contracting COVID‐19 associated with dental care.The COVID‐19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be contagious. Due to the frequency and timing of visits by other dental patients, the nature of the virus, and the characteristics of dental procedures, there is more risk of your contracting the virus simply by being in a dental office. Dental procedures create aerosols which is one way the disease is spread. For the time being we have halted the use of ultrasonic instruments which produce the ultrafine spray that has the potential to linger in the air. We have installed air purifiers in each room that turn the air over every 12 minutes. We use high velocity evacuation systems to capture aerosols at the mouth during treatment. While these measures do not eliminate the risk of infection, they significantly reduce it.Dr. Calender and our team members are making every effort to meet or exceed compliance with guidance from the Center for Disease Control (CDC), the American Dental Association (ADA), and our state board of dentistry to minimize disease transmission and exposure. We welcome your questions about our efforts. I confirm that I have read the Notice above and understand and accept that there is an increased risk of contracting the COVID‐19 virus in the dental office or with dental treatment. I also acknowledge that I could contract the COVID‐19 virus from outside this office and unrelated to my visit here at the same time.I agree to notify Dr. Calender at 817-442-8282 if I develop COVID-19 symptoms within 14 days. _________________________________________? ? _________________________________________ Patient/Caregiver Printed Name ? ? ? ? Signature __________________________________________ _________________________________________Date of service Staff member signature__________________________________________ 14 days from Date of serviceCOVID-19 PATIENT QUESTIONNAIREPatient’s temperature: ______________ Patient’s name: _______________________________________Caregiver’s temperature: ____________ Caregiver’s name: ____________________________________Thank you for coming in to our office today. In light of the COVID-19 virus, please help us better serve and care for you and our entire dental community by reading and responding to the following.Risk factors: A weak or compromised immune system: diabetes, asthma, COPD, cancer treatments, and other diseases or medical conditions) Please let us know of any condition that compromises your immune system and understand that we may ask you to consider rescheduling your treatment to protect you.My risk factors:___________________________________________________________________________Check any boxes which apply:1Have you tested positive for COVID-19?2Have you been tested for COVID-19 and are awaiting results? 3Do you have any of the following respiratory symptoms? fever sore throat dry cough shortness of breath (circle which one, check box)4Have you recently lost your sense of smell or taste?5Do you have any GI symptoms? Diarrhea? Nausea?6Even if you don’t currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?7Have you been in contact with someone who has tested positive for COVID-19 in the last 14 days?8Have you traveled outside the United States by air or cruise ship in the past 14 days?9Have you traveled within the United States by air, bus or train in the past 14 days?Please answer the following if you have been ill:1Have at least 72 hours passed?since recovery, defined as no fever without the use of fever-reducing medications?and Improvement in respiratory symptoms (cough, shortness of breath, difficulty breathing)?2Have at least 7 days passed?since symptoms first appeared?Patient/Caregiver Signature: ____________________________________Date: __________________Staff name ________________________________ Signature______________________________________ ................
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