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3296 Keele Street. Toronto, ON M3M 2H7

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Patient Screening Form

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Patient Screening Form

Patient Screening Form

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Staff screener:

Patient name:

Patient age:

Who answered:

Patient

Others

Contact method:

Email:

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

Yes

Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

Yes

Fever

Yes

New onset of cough

Yes

Worsening chronic cough

Yes

Shortness of breath

Yes

Difficulty breathing

Yes

Sore throat

Yes

Difficulty swallowing

Yes

Decrease or loss of sense of taste or smell

Yes

Chills

Yes

Headaches

Yes

Unexplained fatigue/malaise/muscle aches (myalgias)

Yes

Nausea/vomiting, diarrhea, abdominal pain

Yes

Pink eye (conjunctivitis)

Yes

Runny nose/nasal congestion without other known cause

Yes

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

Yes

I understand the novel coronavirus causes the disease known as COVID-19 abd that it is currently a pandemic. I understand that the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. For this reason, I understand that the federal and provincial authorities have recommended that Ontarians stay home and avoid close contact with other people when at all possible.

I understand the federal and provincial authorities have asked individuals to maintain social distancing of a least two (2) meters (six (6) feet) and I recognize it is not possible to maintain this distance while receiving dental treatment.

I understand that the oral surgery/dental procedures can create water and/or blood spray, which is one way that the novel coronavirus can spread. I understand that the ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus.

I understand that due to the visits of other patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in the dental office.

I agree to complete a COVID-19 screening questionnaire as required by the Ministry of Health.

If I received COVID-19 test results in the part three (3) months, the last results I received were negative. (initial) If applicable, approximate date of test:

I confirm that I am not waiting for the results of a test for COVID-19.

I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days.