Covid-19 Screening Questionnaire - Metcalfe Street Dental - Downtown Ottawa Dental Implant and Family Dental Clinic

Please provide details prior to your next appointment.

Date

Name

Address

Phone Number

Q1: Did the person have close contact with anyone with acute respiratory Illness or travel outside of Canada's capital (area) in the past 14 days? Capital includes both side of the Ottawa river in Ontario & Quebec.

Q2: Does the person have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?

Q3: Does the person have any of the following symptoms:

You can choose more than one.FeverNew onset of coughWorsening chronic CoughShortness of breathDifficulty breathingSore throatDifficulty swallowingDecrease or loss of sense of taste or smellChillsHeadachesUnexplained fatigue / malaise / muscle aches (myalgias)Nausea/vomiting, diarrhea, abdominal painPink eye (conjunctivitis)Runny nose/nasal congestion without other known cause

Q4: If the person is 70 years of age or older, are they experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

Patient Declaration

I/We hereby confirm that the information provided herein is accurate, correct and complete and that the documents submitted along with this application form are genuine.Yes

Coronavirus (COVID-19) Screening Questionnaire

Personal Information:

Screening Questions:

Patient Declaration:

Verification

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