Covid-19
Medical History

By sending this form to us you are confirming the following:

  • The current pandemic brings a number of known risks and number of unknown risks
  • You have chosen to seek dental treatment during this pandemic with the knowledge that much is still unknown about the virus
  • You understand that this virus has a long incubation period during which time carriers of the virus may not show symptoms yet still be highly infectious.
  • Some people may have the virus but may never have any symptoms. Therefore it is impossible to determine who has the virus.
  • You understand that you must assume that anyone anywhere could be infected and infectious
  • You understand that receiving dental treatment means that the UK government’s instruction to maintain social distancing of 2m is not achievable during treatment

This form is to be completed a day
before your appointment.

    Full Name

    Email Address

    Date

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

    - (If NO go 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?

    - I was diagnosed negative by a nasal swab test

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

    - My doctor said I no longer have it because I do not have any symptoms

    - I do not have any symptoms, so I do not have it

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

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

    - Fever

    - Fatigue (feeling tired)

    - Altered or loss of taste/smell

    - Dry cough

    - Trouble breathing

    - Shortness of breath, difficulty breathing

    - Chest tightness

    - Confusion

    - Blueish lips or face

    - Chills/repeated shaking with chills

    - Muscle pain

    - Headache or sore throat

    - Any other flu-like symptoms

    6. Are you in contact with anyone who has been sick and/or confirmed to be COVID-19–positive?
    In the past 14 days have you travelled to any regions outside the travel corridor?

    Some medical conditions have been associated with a greater risk of serious illness or higher mortality if they contract Covid-19.
    The following questions are an attempt to determine your risk. If you answer yes to any of the questions below, your risk is higher to develop serious symptoms if you get infected with the Covid-19 virus. The last question confirms if you have been vaccinated (1 or 2 doses)

    - Are you over age 65?

    - Do you have high blood pressure?

    - If you have high blood pressure, is it controlled?

    - Do you have diabetes?

    - Do you have respiratory problems?

    - Do you have any autoimmune disorders?

    - Are you overweight/ obese?

    - Have you been vaccinated?

    Copyright 2021 by Floss and Smile. All rights reserved.

    Copyright 2021 by Floss and Smile. All rights reserved.