Patient Screening Form

Use this form to screen patients before their appointment and when they arrive for their appointment.
Staff screener:
Patient Name:*
Patient age:*
Phone*
Email*
Who answered:
- Patient
- Other (specify)
specify
Contact Method:
- Phone
- Email
- Other
Do you have a fever or have felt hot or feverish anytime in the last two weeks? (P-S)*
Pre-Screen *
Patient's temperature at appointment:
Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? (P-S)*
Pre-Screen *
Have you experienced a recent loss of smell or taste? (P-S)*
Pre-Screen *
Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19? (P-S)*
Pre-Screen *
Have you returned from travel outside of Canada in the last 14 days? (P-S)*
Pre-Screen *
Have you returned from travel within Canada from a location known affected with COVID-19? (P-S)*
Pre-Screen *
Are you over the age of 60? (P-S)*
Pre-Screen *
Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder? (P-S)*
Pre-Screen *
Any “yes” response must be discussed with the managing dentist immediately.