Boise Dentist Covid Questionnaire

Phone

This field is for validation purposes and should be left unchanged.

Patient Information

Prior To Appointment

Have you had a fever or felt ill in the past 2-3 weeks?

Yes

No

Have you experienced shortness of breath or difficulty breathing?

Yes

No

Have you experienced a cough or heaviness in your chest?

Yes

No

Have you had flu-like symptoms, gastrointestinal upset, headache, or fatigue?

Yes

No

Have you experienced loss of taste or smell?

Yes

No

Are you in contact with any COVID-19 patients?

Yes

No

Do you have any underlying health concerns, autoimmune disorders, diabetes?

Yes

No

Have you traveled in the past 14 days outside the immediate area?

Yes

No

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with dental treatment.