Dentistry On Sheppard

Patient Screening Form

100 Sheppard Ave East, Suite 130, North York, ON, M2N 6N5      416-223-1360

Patient Name:
Patient Age:
E-mail:
Appointment Date
Temperature Check In Office - ℃
Screening QuestionsPre-ScreenIn-Office
YesNoYesNo
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:
  • Fever
  • New Onset of Cough
  • Worsening chronic cough
  • Shortness of breath
  • Difficulty breathing
  • Sore throat
  • Difficulty breathing
  • Decrease or loss of sense of taste or smell
  • Chills
  • Headaches
  • unexplained fatique / malaise / muscule aches (myalgias)
  • Nausea / vomiting, diarrhea, abdominal pain
  • Pink eye
  • 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

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