Dentistry On Sheppard
Patient Screening Form
100 Sheppard Ave East, Suite 130, North York, ON, M2N 6N5
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Temperature Check In Office - ℃
Did you travel outside of Canada in the past 14 days?
Have you been tested for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
Do you have any of the following symptons:
New Onset of Cough
Worsening chronic cough
Shortness of breath
Decrease or loss of sense of taste or smell
unexplained fatique / malaise / muscule aches (myalgias)
Nausea / vomiting, diarrhea, abdominal pain
Runny nose / nasal congestion, without other known cause
Are you over the age of 70, and are you experiencing any of the following: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?
If response to ALL of the screening questions is NO:
COVID Screen Negative
If response to ANY of the screeing questions is YES
COVID Screen Postive
I verify all of this information to be accurate and true.
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