Downloadable COVID-19 screening form for dental patients

May 14, 2020
This patient questionnaire was developed by Dr. Scott Froum to help identify possible viral exposure. It also assists in identifying patients who could experience the most severe effects of COVID-19.
Scott Froum, DDS, Editorial Director

People with severe acute respiratory syndrome coronavirus 2 (SARS CoV-2), which causes the disease COVID-19, have displayed a variety of symptoms ranging from zero to severe. In addition, the mean incubation time for this disease is 5.1 days, with the onset of symptoms occurring two to 14 days after exposure.1

This patient screening questionnaire is designed to ascertain possible exposure and those patients who demonstrate the highest risk of disease severity. This screening process should be implemented 24 hours prior to the patient appointment and then repeated the day of the appointment. We also recommend that you follow up with your patient post-appointment (the author suggests a 10-day time interval) to determine if any changes have occurred. 

Click here to view and download the COVID-19 screening form for dental patients (.pdf).


1. Symptoms of coronavirus. National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. Centers for Disease Control and Prevention. Updated May 8, 2020.

Scott Froum, DDS, a graduate of the State University of New York, Stony Brook School of Dental Medicine, is a periodontist in private practice at 1110 2nd Avenue, Suite 305, New York City, New York. He is the editorial director of Perio-Implant Advisory and serves on the editorial advisory board of Dental Economics. Dr. Froum, a diplomate of the American Board of Periodontology, is a clinical associate professor at SUNY Stony Brook School of Dental Medicine in the Department of Periodontology. He serves on the board of editorial consultants for the Academy of Osseointegration's Academy News. Contact him through his website at drscottfroum.comor (212) 751-8530.