COVID-19: SCREENING QUESTIONNAIRE

Please fill out the following health questionnaire prior to coming in for your appointment.

OR Download, Fill & Print the questionnaire and bring it to your next appointment.

1 Step 1
Have you travelled outside of Canada in the past 14 days?

• Fever

• New onset of cough

• Worsening chronic cough

• Shortness of breath

• Difficulty breathing

• Sore throat

• Difficulty swallowing

• Decrease of 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 or nasal congestion without
    other known cause

What is your COVID vaccination status?
Which vaccination did you take?
Age
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed.
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