Patient Screening PATIENT SCREENING FORM Use this form to screen patients before their appointment Staff screener: Patient Name: Date of screening: MM slash DD slash YYYY Have the patient answer the following questions.Q1. Are you immunocompromised? Yes No Q2: Do you have any of these symptoms? Choose any or all that are new, worsening and not related to other known causes or conditions 2 Fever and/or chills tiredness Cough or barking cough Shortness of breath nose Decrease or loss of taste or smell Muscle aches/joint pain Extreme Sore throat Runny or stuffy/congested Headache Nausea, vomiting and/or diarrhea Abdominal pain Pink eye symptoms Yes No 03: Have you been told (by a doctor, health care provider, public health unit, federal border agent. or other government authority} that you should currently be quarantining,isolating or staying at home? Yes No Q4: In the last lO days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit? Yes No Any “yes” response (other than Q1) must be discussed with the managing dentist immediately. Tell the patient that when they arrive at the office, they will be asked to: Sanitize their hands Have their temperature taken (depending on the dental office*s policies). Factors such as old age. diabetes and end-stage renal disease are generally not considered immunocompromised. Examples of being immunocompromised include individuals: undergoing cancer chemotherapy with untreated HIV infection with CD4 T lymphocyte count less than 200 with combined primary immunodeficiency disorder on prednisone medication - more than 20 mg per day {or equivalent} for more than 14 days on other immune suppressive medications. * Select “No” if all of these apply: you do not have a fever, and your sympLoms have been improving for 24 hours (4B hours if you have nausea, vomiting, and/or diarrhea)
