1920 Ellesmere Rd #201, Scarborough, ON M1H 2V6, Canada
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Patient Screening Form

Staff experiencing symptoms of COVID-19 must immediately go home and not return to work until after consulting with their physician and/or after they are symptom-free following 14 days of self-isolation.

Patient Screening Form

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



Who answered: PatientOther
Contact:

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

Have you had close contact with anyone with acute respiratory Illness or
travelled outside of Ontario in the past 14 days?
YESNO

Do you have a confirmed case of COVID-19 or had close contact with a
confirmed case of COVID-19?
YESNO

Do you have any of the following symptoms:
•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
YESNO

Are you 70 years of age or older, experiencing any of the following
symptoms: delirium, unexplained or increased number of falls, acute
functional decline, or worsening of chronic conditions?
YESNO

Signature

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