Patient Screening Form for COVID-19

Name（名字）*

First NameLast Name

Date of Birth (出生日期)*

Date

Personal Health Number (PHN) 医疗卡号码 (Please make sure the numbers you entered matching with your care card numbers,您填写的卡号请务必和医疗卡号匹配)

Have you tested positive for COVID-19 or are you awaiting/results for a COVID-19 test?(您有做过新冠病毒的检测吗或者正在等待新冠病毒检测结果？)*

yes（是）no（否）

Do you have any of following: 1. Cold or flu-like symptoms 2. Fever 3. Cough 4. Sore throat (您有以下列举的症状吗？1. 感冒或者流感的症状 2.发烧 3.咳嗽 4. 咽喉肿痛 )*

yes（是）no（否）

Are you having shortness of breath or other difficulties breathing? (您有呼吸急促或者其他呼吸困难的症状吗？)*

yes（是）no（否）

Have you experienced recent loss of taste or smell? (您最近有失去味觉或者嗅觉的症状吗？)*

yes（是）no（否）

Even if you do not currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?(即使目前您没有任何以上描述的症状，请问在这过去的14天之内，您是否出现过类似的症状？)*

yes（是）no（否）

Are you, or have you in the last 14 days, in contact with any confirmed COVID-19 positive patients? (请问您是否在这过去的14天和任何确诊新冠病毒的病人有任何接触？)*

yes（是）no（否）

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? (请问您是否患有心脏病，肺病，肾病，糖尿病或者任何自身免疫问题)*

yes（是）no（否）

Body Temperature *

Patient Acknowledgement of COVID-19 Pandemic Risk

This form is adapted from Dental Association of PEI COVID-19 Pandemic Emergency Dental Risk Acknowledge by Patient.

Please read this form and sign where indicated.

1. I understand there is currently a health pandemic associated with COVID-19 and the novel coronavirus.

2. I understand public health authorities have recommended maintaining social distancing of a least 2 meters(6 feet) and it is not possible to maintain this distance while receiving dental treatment.

3. I understand that oral surgery/dental procedures can create water and/or blood spray, and that there may be an elevated risk of contracting and spreading the novel coronavirus in a dental office.

4. I confirm that I do not have any two or more of the following symptoms of COVID-19: fever, new or worsening cough, sore throat, runny nose, or headache, and that this is not currently a period where I am required to self-isolate for 14 days.

5. I hereby consent to have dental treatment completed during the COVID-19 pandemic.

Signature*