COVID-19 Client Screening Form

This form is used to screen clients before their appointment and when they arrive for their appointment.
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Answer the following questions.
SCREENING QUESTIONS
 
PREE SCREEN
IN-OFFICE
Have you had close contact with anyone with acute respiratory Illness or
travelled outside of Ontario in the past 14 days?
yesno
yesno
Do you have a confirmed case of COVID-19 or had close contact with a
confirmed case of COVID-19?
yesno
yesno
Do you have any of the following 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
yesno
yesno
Are you 70 years of age or older, experiencing any of the following
symptoms: delirium, unexplained or increased number of falls, acute
functional decline, or worsening of chronic conditions?
yesno
yesno
Any “yes” response must be discussed with the dental hygienist immediately.
When we arrive, you will be asked to:
o Sanitize your hands.
o Answer the questions again.
o Possibly have your temperature taken.
o Complete a form acknowledging the risk of COVID-19.

We advise:
o Only clients are allowed to come to the office.
o Please wait inside your home, the hygienist will call you.