34441 Eight Mile Road, Suite 114 Livonia, MI 48152

Stanford Dental and Associates

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COVID-19 Patient Questionnaire

COVID-19 Screening Form

Click To Download

COVID-19 Screening Form

Patient’s name:

Date:

Free Text

PREAPPOINTMENT CHECK

1. Have you previously been diagnosed with COVID-19, or do you think you’ve had/have COVID-19?

YES

NO

Free Text

(If NO to question 1, skip to question 5)

2. If YES, when and how were you confirmed positive?

I think I had it.

I had a positive nasal swab test.

I had a positive blood test.

I had a positive saliva test.

I currently have symptoms and am waiting for a test.

3. If you have had COVID-19, how were you confirmed negative?

was diagnosed negative by a nasal swab test.

How many times?

How far apart?

3. If you have had COVID-19, how were you confirmed negative?

I show antibodies to COVID-19 with a blood test.

My doctor said I no longer have it because I don’t have any symptoms.

I don’t have any symptoms, so I don’t have it.

4. If you have had COVID-19, when were you confirmed negative?

24 hours ago

today

10 days after testing

5. Do you currently have (or have you experienced) any of the following symptoms in the past 21 days:

5. Do you currently have (or have you experienced) any of the following symptoms in the past 21 days:

Fever

YES

NO

If fever, how did you measure it?

Fatigue (feeling tired)

Yes

No

Altered or loss of taste/smell

YES

NO

Dry cough

YES

NO

Trouble breathing

YES

NO

Shortness of breath, difficulty
breathing, chest tightness

YES

NO

Confusion

YES

NO

Blueish lips or face

YES

NO

Chills/repeated shaking with chills

YES

NO

Muscle pain

YES

NO

Headache or sore throat

YES

NO

Any other flu-like symptoms

YES

NO

For Any other flu-like symptoms, PLEASE LIST

GI upset or diarrhea

YES

NO

6. Are you in contact with anyone who has been sick and/or confirmed to be COVID-19–positive?

YES

NO

7. In the past 14 days have you traveled to any regions affected by COVID-19?

YES

NO

Free Text

Some medical conditions have been associated with more severe COVID-19 disease. The following questions are an attempt to

determine your risk:

8. Are you over age 65?

YES

NO

9. Do you have high blood pressure?

YES

NO

If you have high blood pressure, is it controlled?

YES

NO

10. Do you have diabetes?

YES

NO

11. Are you overweight?

YES

NO

NO ANSWER

12. Do you have respiratory problems?

YES

NO

13. Do you have any autoimmune disorders?

YES

NO

14. Are there any other conditions you would like to report?

YES

NO

Thank you for your submitting your COVID-19 Screeening Form. We are looking forward to seeing you at your next visit!

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Home
Meet Our Staff
Family Dentistry
Additional Dental Services
Dental Plan Membership
NEW PATIENT
Contact/Location

Browse Our Website

Home
Meet Our Staff
Family Dentistry
Additional Dental Services
Dental Plan Membership
NEW PATIENT
Contact/Location

Contact Information

Phone: (248) 476-4500

Fax: 248-478-8451

Email: stanforddental@sbcglobal.net

Address: 34441 Eight Mile Road, Suite 114

Livonia, MI 48152

Business Hours:

Monday 9:00 am - 5:00 pm

Tuesday 9:00 am - 6:00 pm

Wednesday 11:00 am - 6:00 pm

Thursday 9:00am - 3:00 pm

e/o Friday 9:00 am - 2:00 pm

e/o Saturday 8:00 am - 2:00 pm

Sunday Closed

Visa Payment Accepted

MasterCard Payment Accepted

Discover Payment Accepted

American Express Payment Accepted

Our Location

34441 8 Mile Rd, Livonia, MI 48152

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