Patient Name:

Date of Birth:

Email Address

Screening Questions

1. Do you have any of these symptoms: Fever or chills? Cough? Loss of sense of smell or taste? Difficulty breathing?YesNo

2. Do you have: a sore throat? Loss of appetite? Extreme fatigue or tiredness? Headache? Body ache? Nausea, vomiting or diarrhea?YesNo

3. Have you returned from travel outside Canada in the last 14 days?YesNo

4. Have you had close contact with anyone diagnosed with lab- confirmed or suspected COVID-19?YesNo

5. Have you lived or worked in a setting that is part of a COVID-19 outbreak?YesNo

6. Have you been advised to self-isolate or quarantine at home by public health?YesNo

Any “yes” response for questions 1-5 must be discussed with the managing dentist immediately.
If “yes” to 2 or more of these symptoms: Stay home until you feel better. If symptoms don’t get better or get worse, contact a health care provider, or call 8-1-1about your symptoms and next step.
Patients are advised:
o To sanitize their hands; answer the questions again; have their temperature taken.
o Only patients are allowed to come to the office.
o If possible, to wait in their car until their appointment, call the office when they arrive.
o When patient arrives for their appointment, responses must be confirmed and recorded.

COVID screening form