Patient Name :Date of Appointment :1. Did you/the patient have close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?YESNO2. Do you/the patient have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID -19?YESNO3. Do you/the patient have any of the following symptoms: (please circle if any are YES)-fever-difficulty breathing-shortness of breath-new onset of cough-worsening chronic cough-sore throat-difficulty swallowing-chills-decrease or loss of sense of taste or smell-unexplained fatigue/malaise/muscle aches (myalgias)-nausea/vomiting, diarrhea, abdominal pain -runny nose/nasal congestion without other known cause-headaches-pink eye (conjunctivitis)4. If you/the patient is over 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?5. TEMPERATURE READINGI have answered truthfully and consent to continue care in the dental office today. SendThis field should be left blank
