HEALTH QUESTIONNAIRESUPPLEMENTALHEALTH QUESTIONNAIREOrthodontic Treatment in the Era of COVID-19If you have been exposed to a communicable disease, you may spread the disease to the orthodontist, orthodontic staff, or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:Do you, your child, others accompanying you to today's appointment or anyone you have recently been in contact with have any of the following symptoms?Fever (defined as above 99.6 degrees)? Cough?* Yes NoCough?* Yes NoShortness of breath and/or trouble breathing?* Yes NoPersistent pain, pressure, or tightness in the chest?* Yes NoHave you, your child, others accompanying you to today's appointment or anyone you have recently been in contact with tested positive for or been diagnosed as having COVID•19 or any other communicable disease?* Yes NoIf yes provide approximate dates of illnesssymptom start dateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920symptom end dateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 I understand that if the answer to any of these questions is yes, I may be asked to reschedule today's orthodontic appointment to a later date.Patient Name*Parent/Guardian Name (if applicable)RelationPatient/Parent/Guardian Signature*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
