Pre-screening Questionnaire


Thank you so much for being a part of the Smile Makers family.  The American Dental Association (ADA) and Texas State Board of Dental Examiners (TSBDE) require answering the following questions leading up to your appointment for screening purposes:


  1. Do you have fever or have you felt hot or feverish recetnly (14-21 days)?
  2. Are you having shortness of breath or other difficulties breathing?
  3. Do you have a cough?
  4. Any other flu-like symptoms, such as gastrointestinal upset, headache, hills, muscle pain, or fatigue?
  5. Have you experienced recent loss of taste of smell?
  6. Are you in contact with any confirmed COVID-19 positive patients?  Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
  7. Are you over the age of 60?
  8. Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?
  9. Have you traveled in the past 14 days to any regions affected by COVID-19?


If you can answer yes to any of the questions, we will follow up with a deeper discussion before proceeding with elective treatment, but we will most likely reschedule your upcoming appointment in order to keep everyone safe.  We greatly appreciate your understanding and cooperation.  We look forward to seeing you again soon!



Best regards,


Dr. Bryan Hsu and the Smile Makers Team