Patient Screening Form

Patient Name *

Patient Age *

1. Have you tested positive for COVID-19 in the past 10 days? *

Yes

No

2. Have you been in contact with anyone with confirmed COVID-19 in the past 10 days AND been advised to self-isolate? *

Yes

No

3. Do you have, or have you had within the past 10 days, any of the following symptoms:

Fever (above 37.8-38.0 degrees Celsius) or feeling hot, chills/feverish *

Yes

No

Shortness of breath or other difficulties breathing *

Yes

No

Cough or worsening of a chronic cough *

Yes

No

Flu-like symptoms such as stomach upset, diarrhea, headache, fatigue or sore throat *

Yes

No

Recent alteration or loss of taste or smell *

Yes

No

Any new, unusual symptoms, e.g., feeling unwell, or sudden onset of runny nose, pink eye (conjunctivitis) *

Yes

No

4. Have you been in contact with anyone with any of the above symptoms of possible COVID-19 AND been advised to self-isolate? *

Yes

No

5. Optional: If you have conditions or comorbidities that may make you more vulnerable to COVID-19 that you would like to share, please do so here:

6. Have you travelled in the past 14 days outside of the province and/or country AND been advised to self-isolate? *

Yes

No

"YES" responses to any of these questions would indicate the need for a deeper discussion with the dentist before proceeding with treatment.

7. Optional: Are you fully vaccinated against COVID-19? Fully vaccinated means that it has been at least 14 days since you received the second dose of the Pfizer, Moderna, or AstraZeneca COVID-19 vaccine or the Janssen COVID-19 vaccine.

Yes

No

Prefer not to answer

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COVID-19 Patient Screening