LEEWARDPEDO

Medical History Update

Although dental personnel primarily treat the area in and around the patient's mouth, the mouth is a part of the entire body. Health problems that the patient may have, or medication that the patient may be taking could have an important interrelationship with the dentistry your child will receive. Thank you for answering the following questions.

Patient's Name*

First Last

Has the patient had a fever or felt hot / feverish within the last 10 days?*

YES
NO

Has the patient had shortness of breath or other difficulties breathing?*

YES
NO

You selected YES, Please provide more details*

Does the patient have a cough, runny nose or sore throat?*

YES
NO

Does the patient have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*

YES
NO

You selected YES, Please provide more details*

Has the patient tested positive to COVID-19?*

YES
NO

Date of last symptoms*

MM

DD

YYYY

Patients who are well but who have a sick family member at home should consider postponing elective treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

LEEWARD PEDIATRIC DENTISTRY

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Medical History Update