Patient Health Survey in Burwood, NSW | Sydney Paediatric Dentistry

Our team will contact you to complete this form in the 24 hours prior to your appointment. If the answers to any of your questions change in the lead up to the appointment, please give us a call.

If you, or members of your immediate household, are experiencing any symptoms of illness at all, we ask you to please call us on (02) 9715 3711 to reschedule your appointment.

Patient Name*
First Last
Email*
1. Are you, your child or other’s accompanying you to today’s appointment experiencing symptoms such as fever, headache, runny nose, cough, sore throat or shortness of breath? **

Yes/No
2. Do you/they have any other symptoms, such as a scratchy throat, body aches or runny nose?*

Yes/No
3. Have you had any symptoms in the last 14 days that are new: fever (37.5° or higher), cough, sore throat, shortness of breath (difficulty breathing), runny nose, loss of taste, loss of smell*

Yes/No
4. Have you been in contact with anyone diagnosed with COVID-19 in the last 14 days or been asked to self-isolate by a health official?*

Yes/No
5. Have you been at a place of high concern (close contact venue or casual contact venue) in NSW, Qld, WA, NT or Vic?*

Yes/No
Locations associated with confirmed COVID-19 cases are classified by NSW Health for action. The following venues of concern indicate transmission has occurred after being visited by confirmed cases of COVID 19.

Additional screening question for practices located outside of Greater Sydney and surrounds:
6. Have you been in Greater Sydney, including the Blue Mountains, Central Coast, Wollongong and Shellharbour for any reason since Monday 21 June? (Anyone who has visited Greater Sydney and surrounding areas must follow the stay-at-home rules for 14 days since they left the area unless it is to access essential dental care - please use your professional judgement to determine what you deem as essential and always screen for COVID exposure risk).*

Yes/No
7. I confirm that I will contact the practice to reschedule my appointment if I become aware of any symptoms of illness for the patient, myself or our immediate household(s).*

Yes/No

Patient Health Survey

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Sydney Paediatric Dentistry