ADA Patient Screening Form

An interactive, intuitive, and functional ADA patient screening form template that gives you freedom from paperwork.

By Katherine Ellison on Aug 2, 2025.

Fact Checked by RJ Gumban.

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What Is a ADA Patient Screening Form

form is used by American Dental Association (ADA) as a questionnaire for dental professionals to assess the suitability of a patient for treatment. This form primarily screens for COVID-19-related symptoms in response to the pandemic. It includes screening for common COVID-19-related symptoms and populations that are more susceptible and vulnerable to COVID-19 infection. The goal of the patient screening form is to identify any potential risks or contraindications that may impact the dental treatment, ensuring the safety of the patient and limiting the possible spreading of viral infections. We have designed this template so that it includes all the necessary information for an ADA patient screening form and is more accessible since you can directly interact with the PDF without printing it. These forms can be easily distributed by dental practitioners to their patients to maximize the quality of care and protection of patients’ health. In this guide, you will find instructions on how to utilize this template in detailed steps, a sample template, and various benefits associated with using this form.

ADA Patient Screening Form Template

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How To Use This Template For ADA Patient Screening Forms

It is easy and hustle-free to use our ADA patient screening form template. We designed the template so that it is intuitive to use. If you are not sure about how to approach it, here are some simple steps you can follow:

Step One: Download the PDF

Download the PDF onto your devices before doing anything. We have made this ADA patient screening form template into an interactive PDF, so you can fill it out straightaway on your devices. Alternatively, you can also print it out or access it within the Carepatron template library.

Step Two: Distribute to Your Patients

If you are the dental practitioner yourself, you need to send these forms out to your patients and have them fill them out. Make sure you communicate with your patients, so they can receive these forms in a way that is accessible to them. The eldest generation may not be as familiar with electronic devices as you are.

Step Three: Examine the Forms

After you receive the completed form from your patients, double-check the filled form to ensure all the required information has been provided. If there is any problem with missing information or the readability of their handwriting, make sure you confirm all the details with your patients.

Step Four: Documentation

If the forms are free of errors, it is time to document them in your patient profiling system. Whether you are storing them digitally or physically, these are strictly confidential information and should not be shared without patient consent, so make sure they are stored securely.

Who Can Use this Printable ADA Patient Screening Form (PDF)?

The American Dental Association (ADA) originally developed the ADA patient screening form. Therefore, this patient screening form was made to use by dental practitioners. There is no restriction on what type of dental practitioner you are, and you certainly do not have to be a fully trained dentist to use it. Here are some examples of dental practitioners:

Dental Hygienist
Dental Nurse
Dental Technician
Dental Therapist
Dentist

Nevertheless, if you are working with other types of healthcare professionals who are wanting to screen your patients or clients for COVID-19, ADA patient screening form can still be a decent choice. The nature of content within this form is focused on COVID-19 symptoms and associated risk factors that can make patients vulnerable and susceptible to infection, so feel free to give it a try.

Why Is This Form Useful For Dentists

Identify Risk

Dental care services have direct contact with the oral cavity which constitutes the respiratory system that is the primary pathway of spreading COVID-19. Identifying early and potential risks of COVID-19 before contact with the patient can significantly reduce the odds of spreading COVID-19 during the practice.

Legal Requirements

It is part of the legal requirements in many countries to screen for COVID-19 within the healthcare setting. By using our ADA patient screening form, you can easily satisfy these legal requirements and save yourself from extra annoyance.

Improve Efficiency

We designed our template to ensure it is intuitive and functional. By using a predesigned and consistent ADA patient screening form template, you can save tons of time from doing paperwork and trying to get everything organized.

Benefits of ADA Patient Screening Forms PDF

Maximize patient protection

By using the ADA patient screening form, you can efficiently identify patients with potential COVID-19 symptoms and those that are vulnerable to COVID-19 infection. This provides the opportunity of providing extra care and caution when treating these patients.

Streamline Screening Process

Streamlining the screening process reduces the time and effort needed for these simple but repetitive tasks. It allows dental practitioners to easily and rapidly screen their patients, and utilize their precious minutes on tasks that matter more.

Improved Reliability

The ADA patient screening form is made by the American Dental Association, a credible source of information for dental practitioners around the world. Not saying they provide the best information all the time, but it is certainly very reliable compared to most random resources you found online.

Improved Accessibility

Our ADA patient screening form PDF template has been made interactive, meaning you can fill it out at ease by typing into pre-existing text fields and ticking interactive checkboxes. You can finish the form without printing, rescanning, or converting it into a messy Word document.

Reduce Medical Complications

Respiratory symptoms don’t always have to be COVID-19, although it is the most prevalent respiratory condition for a few years. A certain respiratory infection can lead to lifelong heart valve diseases, like rheumatic heart disease, and they are always associated with oral health. Having these screened out can reduce the risk of your patients getting into messy complications.

Commonly asked questions

To create an ADA patient screening form, you either download the PDF template or access it from our Carepatron template library. You can find the specific steps on how to do this on this page and the linked video.

The ADA patient screening form requires the patient to complete every question that is listed there. It is not a complicated form, and all the questions are easily understandable. If your patient has reading difficulties, try reading it out to them. After all the questions are answered, a patient signature is required at the bottom for them to acknowledge that their statement on the screening form is true to the best of their knowledge.

The ADA patient screening form must be completed for legal requirements and patient safety. It screens for vital information about COVID-19 to limit spreading and protect a vulnerable population. The ADA patient screening form is not the only option out there though, and the healthcare practitioner has the freedom to use any forms that provide an equivalent function