COVID-19 Pre-Screening Questionnaire

PATIENT SCREENING FORM

Patient Name*

First Last

Patient Age*

Your Full Name

First Last

Are you the patient, a parent, or guardian?*

Patient
Parent
Guardian

Have you or anyone in your household travelled outside of Canada or the province 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

Has anyone in your household tested positive to COVID-19 in the past 30 days?*

Yes
No

Do you or anyone in your household have any of the following symptoms:

Fever*

Yes
No

New Onset Cough*

Yes
No

Worsening Chronic Cough*

Yes
No

Shortness of Breath*

Yes
No

Difficulty Breating*

Yes
No

Sore Throat*

Yes
No

Decrease or Loss Of Taste or Smell*

Yes
No

Difficulty Swallowing*

Yes
No

Chills*

Yes
No

Headaches*

Yes
No

Unexplained Fatigue/Malaise/Muscle Aches*

Yes
No

Nausea/Vomiting/Diarrhea/Abdominal Pain*

Yes
No

Pink Eye*

Yes
No

Runny Nose/Nasal Congestion*

Yes
No

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

Yes
No
Does not apply

Have you or anyone in your household been advised to self isolate?*

Yes
No

Is anyone in your household deemed an essential worker and has travelled out of the country within the past 14 days?*

Yes
No

Are you waiting on the results of a COVID-19 test?*

Yes
No

Your Email Address*

We will send you a copy of this form for your records, with instructions for your visit.

Please Sign

I verify that the information I have provided to this form is truthful and complete. I knowingly and willingly consent to have emergency surgical/dental treatment completed during the COVID-19 pandemic.

COVID-19 Patient Screening (2)

PAGE 2 of 2

PATIENT SCREENING FORM