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Patient Screening - Covid-19

Use this form to screen patients before their appointment and when they arrive for their appointment.

Staff screener: *

Patient Name: *

Patient age: *

Who answered: *

Patient

Contact Method: *

Phone Email

Identify yourself and explain the purpose of the call, which is to determine whether there are any special considerations for their dental appointment. Have the patient answer the following questions.

Screening Questions( Pre-Screen)

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

Yes No

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

Yes No

Do you have any of the following symptoms: *

Yes

No

Fever

New onset of cough

Worsening chronic cough

Shortness of breath

Difficulty breathing

Sore throat

Difficulty swallowing

Decrease or loss of sense of taste or smell

Chills

Headaches

Unexplained fatigue/malaise/muscle aches (myalgias)

Nausea/vomiting, diarrhea, abdominal pain

Pink eye (conjunctivitis)

Runny nose/nasal congestion without other known cause

If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplainedor increased number of falls, acute functional decline, or worsening of chronic conditions? *

Yes No

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 close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

Yes No

Do you have any of the following symptoms: *

Yes

No

Fever

New onset of cough

Worsening chronic cough

Shortness of breath

Difficulty breathing

Sore throat

Difficulty swallowing

Decrease or loss of sense of taste or smell

Chills

Headaches

Unexplained fatigue/malaise/muscle aches (myalgias)

Nausea/vomiting, diarrhea, abdominal pain

Pink eye (conjunctivitis)

Runny nose/nasal congestion without other known cause

If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplainedor increased number of falls, acute functional decline, or worsening of chronic conditions? *

Yes No

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