SUPPLEMENTAL HEALTH QUESTIONNAIRE

Orthodontic Treatment in the Era of COVID-19

If 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. Please complete your form prior to your your appointment

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? Shortness of breath and/or trouble breathing? Persistent pain, pressure, or tightness in the chest? Yes No Yes No Yes No Yes No Have 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? Ifyesprovideapproximatedatesofillness _______________________ symptom start date Yes No ________________________ symptom end date 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) _______________________________________________________________ Patient/Parent/Guardian Signature _____________________ Relation _____________________ Date © 2020 American Association of Orthodontists through _______