COVID-19 Patient Screening Form

Patient Name *

For patients less than 16 years of age, this form should be completed by a parent/guardian. Any adult accompanying a patient, should answer for both themselves and the patient.

First Name

Last Name

Date of Birth *

MM

DD

YYYY

1. Have you or someone in your household tested positive for COVID-19 in the past 10 days, or have you been told that you should be isolating? *

Yes

No

2. Have you travelled outside of Canada in the past 14 days? *

*If fully vaccinated for >14 days, select “No”

Yes

No

3. Have you or someone in your household had any of the following signs or symptoms in the past 48 hours? *

Check all that apply

Fever (38ºC or higher)

New or worsening cough

Shortness of breath

Sore throat

Hoarse voice

Difficulty swallowing

Decreased or loss of sense of taste or smell

Chills

Headaches

Unexplained fatigue/malaise/muscle aches

Nausea/vomitting, diarrhea, abdominal pain

Runny nose, sneezing or nasal congestion (in absence of underlying reasons for symptoms such as seasonal allergies and post nasal drip)

None of the above

4. In the past 14 days, have you had close contact with a confirmed or probable case of COVID-19? *

*If fully vaccinated >14 days ago, select “No”

Yes

No

5. If you answered "Yes" to Question 4, did you wear the required and/or recommended PPE according to the type of duties you were performing (e.g., goggles, gloves, mask and gown, and N95 with aerosol generating medical procedures) when you had close contact with a suspected or confirmed case of COVID-19? *

I did not answer "Yes" to Question 4

Yes, I wore the required PPE

No, I was not wearing the required PPE

6. Are you 70 years old AND experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? *

Yes

No

Attestation and Consent *

By checking this box, I confirm that the above information is accurate and truthful. I understand that this information is collected in accordance with the Website Terms and Conditions and the terms of the Privacy Policy on this website and will be reviewed by staff at Dentistry on Main for the purpose of the provision of dental services.