COVID-19 Screening Questionnaire

Full Name

Age

Email address

Phone number

Screening Questions, In-Office:

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

Yes No

Have you tested positive to COVID-19 or had closed contact with a confirmed case of COVID-19 without wearing appropriate PPE?

Yes No

Do you have any of the following symptoms:

Fever, new onset of cough or worsening chronic cough
Shortness of breath, chills or headaches
Difficulty breathing or swallowing
Sore throat, Pink eye
Decrease or loss of sense of taste or smell
Unexplained fatigue/malaise/muscle aches
Nausea/ vomiting, diarrhea, abdominal pain
Runny nose/nasal congestion without other known cause

Any "yes" response must be discussed with the managing dentist immediately.

Yes No

If you are 70 years of age or older, are you experiencing any of the following symptoms:

Yes No

Delirium
Unexplained or increased number of falls
acute functional decline
worsening of chronic conditions

Only patients should attend the office if possible. If possible, please wait in car until your appointment, call the office at (905)332-6950 when you arrive. If you develop any of the above symptoms within 14 days, please give us a call.

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