• Covid-19 Patient Screening Form

    Fairway Dental Clinic

    385 Fairway Road South, Unit #203
    Kitchener, Ontario, Canada N2C 2N9
    Phone: 519-893-9494

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  • Fever and/or chills Temperature of 37.8 degrees Celsius/100 F or higher.
    Cough or barking cough (croup) Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have.
    Shortness of breath Shortness of breath Not related to asthma or other known causes or conditions you already have.
    Sore throat Sore throat Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have.
    Difficulty swallowing Difficulty swallowing Painful swallowing (not related to other known causes or conditions you already have.)
    Decrease or loss of smell or taste Decrease or loss of smell or taste Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have.
    Pink eye Pink eye Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have.)
    Runny or stuffy/congested nose Runny or stuffy/congested nose Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have.
    Headache Headache Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have.)
    If you received a COVID-19 vaccination in the last 48 hours and are experiencing a mild headache that only began after vaccination, select “No.”
    Digestive issues like nausea/vomiting, diarrhea, stomach pain Digestive issues like nausea/ vomiting, diarrhea, stomach pain. Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have.
    Muscle aches/joint pain Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have.)
    If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild muscle aches/joint pain that only began after vaccination, select “No.”
    Fatigue Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have.
    If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select “No.”
    Falling down often For older people.
  • This can be because of an outbreak or contact tracing.
  • If you have since tested negative on a lab-based PCR test, select “No.
  • If you are fully vaccinated* and have not been advised to self-isolate by public health, select “No”.
  • If you are fully vaccinated and/or have already gone for a test and got a negative result, select "No." ** Fully vaccinated is defined as an individual ≥14 days after receiving their second dose of a two-dose COVID19 vaccine series or their first dose of a one-dose COVID-19 vaccine series.
  • If you are not fully vaccinated and you live with someone who travelled outside of Canada, see Notes below.
  • If you are fully vaccinated, select “No.” If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”
  • Note: Effective July 5, 2021, fully vaccinated Canadians may be exempt from post-travel COVID-19 quarantine restrictions. For those individuals who are not fully vaccinated AND either 1) live with an individual who has recently traveled outside of Canada OR 2) live with an individual who is self-isolating due to a high-risk exposure: These individuals are permitted to attend work, but they are required to stay home except for essential reasons for the duration of the contact’s isolation period. Essential reasons include: attending school/child care/work and essential errands such as, obtaining groceries, attending medical appointments or picking up prescriptions.
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