HAWAII ENDODONTICS Covid-19 Screening Questionnaire Name* First Last Date Of Birth* MM DD YYYY Have you been completely vaccinated for COVID-19?*YESNOPREFER NOT TO ANSWERDo you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*YESNOAre you/they having shortness of breath or other difficulties breathing?*YESNODo you/they have a cough?*YESNOAny other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*YESNOYou selected YES, Please provide more details*Have you/they experienced recent loss of taste or smell?*YESNOAre you/they in contact with any confirmed COVID-19 positive patients?*YESNOIs your/their age over 60?*YESNODo you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*YESNOHave you/they traveled in the past 14 days outside your state? (as relevant to your location)*YESNOWhere have you traveled to?*Have you been tested positive to COVID-19?*YESNOWhen did you get tested positive to COVID-19?* MM DD YYYY Have you been tested again as negative to COVID-19?*YESNOWhen did you get tested negative to COVID-19?* MM DD YYYY Patients who are well but who have a sick family member at home with COVID-19 should consider postponing/rescheduling treatment. Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with dental treatment.COVID-19 Consent*• I knowingly and willingly consent to have emergency dental treatment completed during the COVID-19 pandemic. • I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing. Dental procedures create water spray which is how the disease is spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 Virus. • I understand that due to the visits of other patients, the characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental office. • I have been made aware of the HDA, CDC, and ADA guidelines that under the current pandemic all non-urgent dental care is not recommended. I understand this risk and confirm that I have an urgent or emergent condition which constitutes severe pain and/or active acute infection. I attest that my pain is severe, and not mild or moderate. • I confirm I am seeking treatment for a condition that meets these criteria. • I confirm that I do not feel sick, have a fever, chills, cough, or any flu-like symptoms. I confirm that I am not presenting any of the following symptoms of COVOID-19 listed below: - Fever - Shortness of Breath • Dry Cough - Runny Nose - Sore Throat • I understand that air travel significantly increases my risk of contracting and transmitting the COVlD-19 virus. And the CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has, and this is not possible with dentistry. • I verify that I have not traveled outside the United States (Europe, Middle East, east Asia or others) in the past 14 days to countries that have been affected by COVID-19. • I verify that I have not traveled domestically within the United States by commercial airline, bus, or train within the past 14 days. I agree to above mentioned consent.Signature of Patient or Legal Guardian*Today's Date: 05/05/2024UsernameThis is a hidden field Consent Text• I knowingly and willingly consent to have emergency dental treatment completed during the COVID-19 pandemic. • I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing. Dental procedures create water spray which is how the disease is spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 Virus. • I understand that due to the visits of other patients, the characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental office. • I have been made aware of the HDA, CDC, and ADA guidelines that under the current pandemic all non-urgent dental care is not recommended. I understand this risk and confirm that I have an urgent or emergent condition which constitutes severe pain and/or active acute infection. I attest that my pain is severe, and not mild or moderate. • I confirm I am seeking treatment for a condition that meets these criteria. • I confirm that I do not feel sick, have a fever, chills, cough, or any flu-like symptoms. I confirm that I am not presenting any of the following symptoms of COVOID-19 listed below: - Fever - Shortness of Breath • Dry Cough - Runny Nose - Sore Throat • I understand that air travel significantly increases my risk of contracting and transmitting the COVlD-19 virus. And the CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has, and this is not possible with dentistry. • I verify that I have not traveled outside the United States (Europe, Middle East, east Asia or others) in the past 14 days to countries that have been affected by COVID-19. • I verify that I have not traveled domestically within the United States by commercial airline, bus, or train within the past 14 days.HideAgeThis is a hidden field ← Sgill → Matteocruz