SUPPLEMENTAL HEALTH QUESTIONNAIRE

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Have you, your child, or others accompanying you to today’s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease? *

Yes
No

If yes, when? Date:

A Fever (defined as above 99.6 degrees) *

Yes
No

What is your actual temperature?

Selected Value: 95

A Cough? *

Yes
No

Shortness of Breath and/or Trouble Breathing? *

Yes
No

Persistent Pain, Pressure, or Tightness in the Chest? *

Yes
No

I understand that if the answer to any of these questions is yes, I will be asked to reschedule today’s orthodontic appointment. *

I agree
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SUPPLEMENTAL HEALTH QUESTIONNAIRE

MySmile Expert