Downtown Whitby Dentistry

Patient Screening Form

130 Byron Street North, Whitby, ON, L1N 4M9      905-430-7045

Patient Name:
Patient Age:
E-mail:
Date
Temperature Check In Office - ℃
Screening QuestionsPatient Answer
YesNo
Q1: Are you fully vaccinated against COVID-19 and / or aged 11 or younger?1
Q2: In the last 14 days have you been directed by a border agent to comply with federal quarantine requirements due to international travel?
Q3: In the last 5 days (if fully vaccinated) / 10 days (if unvaccinated or immunocompromised), have you experienced any of these symptoms?2
  • Fever and/or chills
  • Cough or barking cough
  • Shortness of breath
  • Decrease or loss of sense of taste or smell
  • Muscle aches/joint pain
  • Extreme tiredness
  • Sore throat
  • Runny or stuffy/congested nose
  • Headache
  • Nausea, vomiting and/or diarrhea
Q4: Do any of the following apply?3
  • You live with someone who is currently isolating because of a positive COVID-19 test
  • You live with someone who is currently isolating because of COVID-19 symptoms
  • You live with someone who is isolating while waiting for COVID-19 test results
Q5: In the last 5 days (if fully vaccinated)/ 10 days (if unvaccinated or immunocompromised), have you tested positive on a rapid antigen test, molecular test, or home-based self-testing kit?4
Q6: Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

1If you are immunocompromised, select “No.”

2Select “No” if all of these apply:

  • you have completed your isolation period or you tested negative for COVID-19 on one PCR test or rapid molecular test or two rapid antigen tests taken 24 to 48 hours apart, and
  • you do not have a fever, and
  • your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea)

3Select “No” if you:

  • are 18 or older and have received your booster dose, or
  • are 17 or younger and are fully vaccinated, or
  • completed your isolation after testing positive in the last 90 days (using a rapid antigen, rapid molecular, or PCR test)

4Select “No” if you have already completed your isolation period because your symptoms started before your positive test result, and

  • you do not have a fever, and
  • your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea)

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