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

Age
Are you experiencing any of the following symptoms?
Delirium
Unexplained or increased number of falls
Acute functional decline
Worsening of chronic conditions
I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed.
keyboard_arrow_leftPrevious
Nextkeyboard_arrow_right
FormCraft – WordPress form builder