Covid Screening | Kitchener Waterloo Prosthodontics

Covid-19 Patient Screening Form

First Name

Last Name

I have not had close contact with anyone with acute respiratory illness or travelled outside Ontario in the past 14 days

I am not experiencing the symptoms:Fever • New onset of cough • Worsening chronic cough • Shortness of breath • Difficulty breathing • Sore throat • Difficulty swallowing • Decrease or loss of sense of taste or smell • Chills • Headaches • Unexplained fatigue/malaise/muscle aches (myalgias) • Nausea/vomiting, diarrhea, abdominal pain • Pink eye (conjunctivitis) • Runny nose/nasal congestion without other known cause

I haven’t been in close contact with a Covid-19 patient in the last 14 days

I am 70 years of age or older, I am NOT experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

Initials

Date

I declare that the info I’ve provided is accurate & complete

Phone

Thanks for submitting!

Covid-19 Patient Screening Form

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