Burlington
, ON
L7N 2R4
[email protected]
Call Us:
(905) 634-3665
Email Us:
[email protected]
Family Dentistry
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COVID-19 Screening Questionnaire
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COVID-19 Screening Questionnaire
Name
*
Date
*
Email
Phone
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, loss of taste or smell, chills, headaches, unexplained fatigue, pink eye, runny nose/ congestion without other known cause?
Yes
No
Have you traveled outside Ontario in the last 14 days?
Yes
No
Has there been any significant changes to your health since your last visit?
Yes
No
If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?
Yes
No
In order to protect out patients health, we reserve the right to reschedule your appointment.
Signature (Print your name)
*