Pre-Appointment COVID-19 Screening Intake Form Patient Name:*1. Have you had close contact with anyone with acute respiratory Illness or travelled outside of Ontario in the past 14 days?YesNo2. Do you have a confirmed case of COVID-19 or have you had close contact with a confirmed case of COVID-19?YesNo3. Do you have any of the following symptoms: FeverYesNoWorsening chronic cough ?YesNoNew onset of cough ?YesNoShortness of breath ?YesNoDifficulty breathing ?YesNoSore throat ?YesNoDifficulty swallowingYesNoDecrease or loss of sense of taste or smell ?YesNoChills ?YesNoHeadaches ?YesNoUnexplained fatigue/malaise/muscle aches (myalgias) ?YesNoNausea/vomiting, diarrhea, abdominal pain ?YesNoPink eye (conjunctivitis) ?YesNoRunny nose/nasal congestion without other known cause ?YesNo4. If you are 70 years of age or older, are you experiencing any of the following symptoms:Not applicabledelirium ?YesNounexplained or increased number of falls?YesNoworsening of chronic conditions?YesNoI understand that Provincial Health Services has asked individuals to maintain social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self- isolate by Provincial Health, the CDC or any other governmental health agency.I verify that the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have my dental treatment completed during the COVID-19 pandemic. *(Signature)
