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ADA COVID-19 SCREENING FORM
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COVID-19 Screen | ART Orthodontics
Dr Khatami | Davie Fl
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Are you/they having shortness of breath or other difficulties breathing?
Do you/they have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you/they experienced recent loss of taste or smell?
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.
Is your/their age over 60?
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
Have you/they been tested for COVID-19
If yes to being tested for COVID-19: Please indicate reason, date, location, mode of test, and result:
If you tested positive for COVID-19: When and how long did you self-quarantine?