COVID-19 Triaging Questionnaire for Urgent Dental Treatment COVID-19 Triaging Questionnaire for Urgent Dental Treatment Name* First Last Date of Birth* DD slash MM slash YYYY Address* Street Address Address Line 2 City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* COVID-19 Risk AssessmentDo 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 AssessmentPlease 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/DrugsPlease list any medications not already listed including recreational usage Urgent Dental ProblemPlease describe the nature of your urgent dental problem SwellingOnly 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 TraumaOnly 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 formDental PainAre 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 UploadAccepted file types: jpg, gif, png, Max. file size: 2 MB. ConsentConsent* 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* DD slash MM slash YYYY CAPTCHA
