Trio Dentistry - Pre-Patient Screening Form

Full Name:

E-mail:

	Yes	No
Have you had close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?
Do you have a confirmed case of Covid19 of had close contact with a confirmed case of Covid-19?

Do you have any of the following symptoms?

If you are over the age of 70, are you experiencing any of the following symptoms:

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed today during the COVID-19 pandemic

	Yes	No
Fever
New Onset of Cough
Worsening Chronic Cough
Shortness of Breath
Difficulty Breathing
Sore throat
Difficulty Swallowing
Decrease or loss of sense of taste of smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal cramps (of unknown origin)
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause

	Yes	No	N/A
Delirium
Unexplained or increased number of falls
Acute functional decline
Worsening of chronic conditions

Patient Pre-Screening Form

3163 Winston Churchill Blvd., Mississauga, ON L5L 2W1 905-812-1818

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