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Health Questionnaire Supplement

The AAOIC Supplemental Health Questionnaire is designed to assess exposure to communicable diseases, including COVID-19, prior to orthodontic appointments. It includes questions about recent diagnoses, symptoms like fever and cough, and requires a signature from the patient or parent. The purpose is to minimize the risk of disease transmission in the practice.

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3 views

Health Questionnaire Supplement

The AAOIC Supplemental Health Questionnaire is designed to assess exposure to communicable diseases, including COVID-19, prior to orthodontic appointments. It includes questions about recent diagnoses, symptoms like fever and cough, and requires a signature from the patient or parent. The purpose is to minimize the risk of disease transmission in the practice.

Uploaded by

heatherwanabe
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Patient Name: _______________________________

AAOIC SUPPLEMENTAL HEALTH QUESTIONNAIRE

If you have been exposed to a communicable disease, you may spread the disease to the
orthodontist, orthodontic staff, or other patients/parents in the practice. Therefore, prior to each
appointment, we will be asking the following questions to reduce the chances of transmission:
Have you, your child, or anyone either of you have come in contact with tested positive for or
been diagnosed as having COVID-19 or any other communicable disease?
Yes________ No________

If yes, when were you, your child, or the person you had contact with diagnosed?
Date__________________

Do you, your child, or anyone either of you have come in contact with have:
•A Fever (defined as above 99.6 degrees) Yes________ No________
•A Cough? Yes________ No________
•Shortness of Breath and/or Trouble Breathing? Yes________ No________
•Persistent Pain, Pressure, or Tightness in the Chest? Yes________ No________

Have you, your child, or anyone either of you have come in contact with had any of the following
symptoms within the last 14 days:
•A Fever (defined as above 99.6 degrees) Yes________ No________
•A Cough? Yes________ No________
•Shortness of Breath and/or Trouble Breathing? Yes________ No________
•Persistent Pain, Pressure, or Tightness in the Chest? Yes________ No________

______________________________ _____________
Patient/Parent’s Signature Date

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