Have you, your child, or others accompanying you to today’s appointment been tested positive for or been diagnosed as having Covid-19?
 Yes
 No

If so, when?

Do you, your child, or others accompanying you to today’s appointment have:
 A Fever (defined as above 99.6 degrees)
 A Cough
 Shortness of Breath and/or Trouble Breathing
 Persistent pain, pressure or Tightness in the chest?
 None

Do you have fever or have you felt hot or feverish recently (14-21 days)?
 Yes
 No

Are you having shortness of breath or other difficulties breathing?
 Yes
 No

Do you have a cough?
 Yes
 No

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
 Yes
 No

Have you experienced recent loss of taste or smell?
 Yes
 No

Are you in contact with any confirmed COVID-19 positive patients? 
 Yes
 No

Is your age over 60?
 Yes
 No

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
 Yes
 No

Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
 Yes
 No

If any of you have any of these symptoms or have recently tested positive for or been diagnosed with Covid-19, you will be asked to reschedule your orthodontic appointment.