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Patient Screening Form
Fairway Dental Clinic
385 Fairway Road South, Unit #203
Kitchener, Ontario, Canada N2C 2N9
Phone: 519-893-9494
Today's Date
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Date Format: DD slash MM slash YYYY
Patient Name
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First
Middle
Last
Date of Birth
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DD
MM
YYYY
Age
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Home Phone
Cell Phone
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Email
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Work Phone
Extension Number
Date of Appointment
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Date Format: DD slash MM slash YYYY
Time
*
:
HH
MM
AM
PM
Screening Questions Pre-Screen
Have you had contact with anyone with acute respiratory illness or travelled outside of Canada in the past 14 days?
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YES
NO
Have you ever tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE (facemask)?
*
YES
NO
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?
*
YES
NO
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?
*
YES
NO
Patient Signature (Write your Name)
*
Date
*
Date Format: DD slash MM slash YYYY
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