Please note that in accordance with regulations mandated by the Royal College of Dentists Surgeons of Ontario, our office is required to have this screening form completed TWICE - once at the time an appointment is booked, and a second time immediately before entering our office. Thank-you for your understanding and patience which in turn enables us to not only comply with this College requirement, but to also do everything in our power to keep our patients, staff and our families safe during these challenging times.
ESSENTIAL PATIENT COMPANION Covid-19 Screening Form
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Minutes
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AM/PM Option
COMPANION First Name
*
COMPANION Last Name
*
PATIENT First Name
*
PATIENT Last Name
*
Do YOU, the COMPANION, have any of the following symptoms?
*
Yes
No
Fever
New onset of cough
Worsening of 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 or nasal congestion without other known cause
Pain or pressure in chest
Sluggishness or lack of appetite
Have YOU, the COMPANION, travelled outside of Canada in the past 14 days?
*
Yes
No
Have YOU, the COMPANION, tested positive for Covid-19 within the past three weeks?
*
Yes
No
Have YOU, the COMPANION, had close contact with a suspected or confirmed case of Covid-19 within the past month?
*
Yes
No
Do any people who live with YOU, the COMPANION, have any of the symptoms outlined above?
*
Yes
No
How old are YOU, the COMPANION?
*
Are YOU, the COMPANION, experiencing any of the following symptoms? (Please answer YES or NO to each)
*
YES
NO
Delirium
Unexplained or increased number of falls
Acute functional decline
Worsening of chronic conditions
Submit
Should be Empty: