{"id":454,"date":"2020-05-07T17:32:18","date_gmt":"2020-05-07T17:32:18","guid":{"rendered":"https:\/\/www.palmetto-smiles.com\/dentist\/?page_id=454"},"modified":"2020-05-13T16:34:18","modified_gmt":"2020-05-13T16:34:18","slug":"health-questionnaire","status":"publish","type":"page","link":"https:\/\/www.palmetto-smiles.com\/dentist\/health-questionnaire\/","title":{"rendered":"Orthodontic Health Questionnaire"},"content":{"rendered":"[vc_row type=&#8221;full_width_background&#8221; full_screen_row_position=&#8221;middle&#8221; bg_color=&#8221;#0a529c&#8221; scene_position=&#8221;center&#8221; text_color=&#8221;dark&#8221; text_align=&#8221;left&#8221; top_padding=&#8221;4%&#8221; bottom_padding=&#8221;4%&#8221; overlay_strength=&#8221;0.3&#8243; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221; shape_type=&#8221;&#8221;][vc_column column_padding=&#8221;padding-4-percent&#8221; column_padding_position=&#8221;all&#8221; background_color=&#8221;#ffffff&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_link_target=&#8221;_self&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;20px&#8221; width=&#8221;1\/1&#8243; tablet_width_inherit=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; column_border_width=&#8221;none&#8221; bg_image_animation=&#8221;none&#8221;][vc_column_text css=&#8221;.vc_custom_1588982295272{padding-bottom: 2% !important;}&#8221;]\n<h3>Orthodontic Health Questionnaire<\/h3>\n[\/vc_column_text]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f453-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"453\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/dentist\/wp-json\/wp\/v2\/pages\/454#wpcf7-f453-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"453\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f453-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<p class=\"thrid-form-input\"><label> Patient's Full Name*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span> <\/label>\n<\/p>\n<p class=\"thrid-form-input\"><label> Parent\/Guardian's Full Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"parent-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"parent-name\" \/><\/span> <\/label>\n<\/p>\n<p class=\"thrid-form-input\"><label> Email*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span> <\/label>\n<\/p>\n<p class=\"half-form-input\"><label>Have you, your child, or others accompanying you to today\u2019s appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"test-positive\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"test-positive\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"test-positive\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n<\/p>\n<p class=\"half-form-input\"><label>If yes, when?*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"yes-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"yes-date\" \/><\/span><\/label>\n<\/p>\n<div style=\"clear:both; padding-bottom: 10px;\">\n<\/div>\n<p><b>Do you, your child, or others accompanying you to today\u2019s appointment or other recent acquaintances have:<\/b>\n<\/p>\n<p class=\"half-form-input\"><label>A Fever (defined as above 99.6 degrees)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"fever\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"fever\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"fever\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n<\/p>\n<p class=\"half-form-input\"><label>A Cough?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cough\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"cough\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"cough\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n<\/p>\n<p class=\"half-form-input\"><label>Shortness of Breath and\/or Trouble Breathing?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"breathing\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"breathing\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"breathing\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n<\/p>\n<p class=\"half-form-input\"><label>Persistent Pain, Pressure, or Tightness in the Chest?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"chest-pain\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"chest-pain\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"chest-pain\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n<\/p>\n<div style=\"clear:both; padding-bottom: 20px;\">\n<\/div>\n<div style=\"padding: 2%; background-color: #f7f7f7; margin-bottom: 2%;\">\n\t<h4>AAOIC SUPPLEMENTAL INFORMED CONSENT<br \/>\nOrthodontic Treatment in the Era of COVID-19\n\t<\/h4>\n\t<p style=\"font-size: 15px; line-height: 21px;\">Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as \u201cCoronavirus,\u201d at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.\n\t<\/p>\n\t<p style=\"font-size: 15px; line-height: 21px;\">Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. \u201cSocial Distancing\u201d nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times.\n\t<\/p>\n\t<p><label>Although exposure is unlikely, do you accept the risk and consent to treatment?*<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"accept-the-risk\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"accept-the-risk\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"accept-the-risk\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<p><em>I understand that if the answer to any of these questions is yes, I will be asked to reschedule today\u2019s orthodontic appointment.<\/em>\n<\/p>\n<p><label>Patient\/Parent\u2019s Signature <\/label><br \/>\n<div class=\"wpcf7-form-control-signature-global-wrap\" data-field-id=\"patient-signature\">\n\t\t\t\t<div class=\"wpcf7-form-control-signature-wrap\" style=\"width:350px;height:140px;\">\n\t\t\t\t\t<div class=\"wpcf7-form-control-signature-body\">\n\t\t\t\t\t\t<canvas data-color=\"#333333\" data-background=\"#f2f2f2\" id=\"wpcf7_patient-signature_signature\" class=\"patient-signature\"><\/canvas>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"wpcf7-form-control-clear-wrap\">\n\t\t\t\t\t<input id=\"wpcf7_patient-signature_clear\" type=\"button\" value=\"Clear\"\/>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<span class=\"wpcf7-form-control-wrap wpcf7-form-control-signature-input-wrap patient-signature\">\n\t\t\t\t<input aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"hidden\" name=\"patient-signature\" id=\"wpcf7_input_patient-signature\"\/><input type=\"hidden\" name=\"patient-signature-attachment\" id=\"wpcf7_input_patient-signature_attachment\"\/><input type=\"hidden\" name=\"patient-signature-inline\" id=\"wpcf7_input_patient-signature_inline\"\/>\n\t\t\t<\/span>\n\t\t\t\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Send\" \/>\n<\/p><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"0\"\/><script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n[\/vc_column][\/vc_row]\n","protected":false},"excerpt":{"rendered":"<p>[vc_row type=&#8221;full_width_background&#8221; 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