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? Yes No 2. Do you have a confirmed case of COVID-19 or have you had close contact with a confirmed case of COVID-19? Yes No 3. Do you have any of the following symptoms: Fever Yes No Worsening chronic cough ? Yes No New onset of cough ? Yes No Shortness of breath ? Yes No Difficulty breathing ? Yes No Sore throat ? Yes No Difficulty swallowing Yes No Decrease or loss of sense of taste or smell ? Yes No Chills ? Yes No Headaches ? Yes No Unexplained fatigue/malaise/muscle aches (myalgias) ? Yes No Nausea/vomiting, diarrhea, abdominal pain ? Yes No Pink eye (conjunctivitis) ? Yes No Runny nose/nasal congestion without other known cause ? Yes No 4. If you are 70 years of age or older, are you experiencing any of the following symptoms: Not applicable delirium ? Yes No unexplained or increased number of falls? Yes No worsening of chronic conditions? Yes No I 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)
