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 NoQ2: Do you have any of these symptoms? Choose any or all that are new, worsening and not related to other known causes or conditionsFever and/or chills tiredness Cough or barking cough Shortness of breath nose Decrease or loss of taste or smellMuscle aches/joint pain ExtremeSore throatRunny or stuffy/congestedHeadacheNausea, vomiting and/or diarrheaAbdominal painPink eyesymptoms* Yes No03: 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 NoQ4: 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 NoAny “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 handsHave 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 chemotherapywith untreated HIV infection with CD4 T lymphocyte count less than 200with combined primary immunodeficiency disorderon prednisone medication - more than 20 mg per day {or equivalent} for more than 14 dayson other immune suppressive medications. * Select “No” if all of these apply: you do not have a fever, andyour sympLoms have been improving for 24 hours (4B hours if you have nausea, vomiting, and/or diarrhea)
