COVID Questionnaire | PURE Dental Hygiene

Covid-19 Health Questionnaire

First Name

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

Yes

Last Name

Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19? *

Yes

Do you have any of the following symptoms: • Fever • New onset of cough • Worsening chronic cough • Shortness of breath • Difficulty breathing • Sore throat • Difficulty swallowing • Decrease or 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/nasal congestion without other known cause *

Yes

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

Yes

If response to ALL of the screening questions is NO: COVID Screen Negative

If response to ANY of the screening questions is YES: COVID Screen Positive

If you screen POSITIVE as per guidelines above, PLEASE let me know as soon as possible. I will have to postpone your appointment until any illness has resolved. Also--contact your medical health care provider or Telehealth Ontario at 1-866-797-0000 immediately for further instructions. You can also access Public Health Ontario’s self-assessment tool at: https://covid-19.ontario.ca/self-assessment/

I declare that the info I’ve provided is accurate & complete

Initials

Date

Thanks for submitting!