COVID-19 Triaging Questionnaire for Urgent Dental Treatment

Name*
First Last
Date of Birth*
Date Format: DD slash MM slash YYYY
Address*
Street Address Address Line 2 City ZIP / Postal Code Country
Phone*
Email*
COVID-19 Risk Assessment
Do you have a confirmed diagnosis of COVID-19?*
- Yes
- No
Have you, or anyone living with you had contact with someone with a confirmed or suspected diagnosis of COVID-19?*
- Yes
- No
Have you, or anyone living with you returned from overseas in the last 14 days?*
- Yes
- No
Do you, or anyone living with you have the following symptoms;*
- Sore throat
- Cough
- Shortness of breath
- High temperature (38°C)
- None
Medical Health Assessment
Please tick YES or NO for each medical condition AND write down medication taken if applicable.
Heart murmur*
- Yes
- No
If yes, details/medication
Heart Attack*
- Yes
- No
If yes, details/medication
Rheumatic fever*
- Yes
- No
If yes, details/medication
Open heart surgery*
- Yes
- No
If yes, details/medication
High blood pressure*
- Yes
- No
If yes, details/medication
Stroke*
- Yes
- No
If yes, details/medication
Asthma*
- Yes
- No
If yes, details/medication
Chest & lung disease*
- Yes
- No
If yes, details/medication
Sinus/hay fever*
- Yes
- No
If yes, details/medication
Epilepsy*
- Yes
- No
If yes, details/medication
Diabetes*
- Yes
- No
If yes, details/medication
Kidney Problems*
- Yes
- No
If yes, details/medication
Gastric Problems*
- Yes
- No
If yes, details/medication
Depressive illness*
- Yes
- No
If yes, details/medication
Radiotherapy/Chemotherapy*
- Yes
- No
If yes, details/medication
Smoker*
- Yes
- No
If yes, how many per day
Artificial/prosthetic joint*
- Yes
- No
If yes, please state when and what prosthesis was placed
Pregnant female*
- Yes
- No
If yes, please state due date
Medications/Drugs
Please list any medications not already listed including recreational usage
Urgent Dental Problem
Please describe the nature of your urgent dental problem
Swelling
Only fill in this section if there is swelling.
Is there visible swelling? (if no, go to the next section)*
- Yes
- No
If yes, when did it start and how has it changed since it started?
Can you eat/drink
- Yes
- No
Is your swallowing or breathing affected?
- Yes
- No
Are you taking antibiotics?
- Yes
- No
If yes, please state the name, dose, frequency, and date you started taking them
Have you taken photo(s) of the swelling? These can be uploaded at the end of the form.
- Yes
- No
Dental Trauma
Only complete this section if you have suffered dental trauma. If you are experiencing bleeding that is severe and ongoing please ring the hospital immediately for advice.
Have you suffered a dental trauma*
- Yes
- No
If yes, please describe the trauma: When, what and how did it happen?
Note: Photos can be uploaded at the end of this form
Dental Pain
Are you experiencing pain?
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Please indicate (tick next to) your level of pain: 0-10 (0 = nothing and 10 = worst pain)
Have you taken medications for the pain?
- Yes
- No
If yes, please list which medications and how often
Photo(s)
If appropriate, please feel free to take a maximum of 2 photos and upload them here
Photo Upload
Accepted file types: jpg, gif, png.
Consent
Consent*
I CONFIRM THAT THE INFORMATION ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Consent*
I agree to the privacy policy.
Our Practice follows the rules set out below whenever we collect, use, store or disclose information about your health.

Collecting your health information:
When we collect health information from you we will:
-Only collect the information for the purpose of treating you (or for some related purpose)
-Collect information directly from you unless you have authorised us to collect the information from someone else (or we have some other lawful reason for collecting the information from someone else); and
-Tell you why we are collecting the information and what we will do with it.

Using your health information:
We will not use your health information for any purpose other than for the purpose of treating you unless we get your consent or we will use your information in a way that doesn’t identify you (or where we have some lawful reason for doing so).

Storing your information:
We will store your health information securely so that only authorised people can access or use your information.

Disclosing your health information:
We will not disclose your health information to anyone without your consent unless we have a lawful reason for doing so.

Access and correction of your health information:
You can ask us to confirm whether we hold information about you. If we hold information about you, you have the right to access the information.

You can ask us to correct any information that we hold about you if you think that the information is inaccurate. If we refuse to correct your information, you can ask us to put a note on your information that states that you have asked for the correction to be made.

Enquiries:
If you have any concerns about any matter relating to your health information, please ask to speak to our privacy officer.
Completed by:*
- Patient (self)
- Parent
- Guardian
Name
First Last
Date*
Date Format: DD slash MM slash YYYY
CAPTCHA

COVID-19 Triaging Questionnaire for Urgent Dental Treatment

COVID-19 Risk Assessment

Medical Health Assessment

Urgent Dental Problem

Swelling

Dental Trauma

Dental Pain

Photo(s)

Consent