COVID-19 Screening Wanless

    Full Name:
    Date:

    1. Do you have any of the following new or worsening symptoms or signs?

    • Fever or chills YesNo
    • Difficulty breathing or shortness of breath YesNo
    • Cough YesNo
    • Sore throat, trouble swallowing YesNo
    • Runny nose/stuffy nose or nasal congestion YesNo
    • Decrease or loss of smell or taste YesNo
    • Nausea, vomiting, diarrhea, abdominal pain YesNo
    • Not feeling well, extreme tiredness, sore muscles YesNo

    2. Have you tested positive for COVID-19? YesNo
    3. Are you waiting for the results of a COVID-19 test? YesNo
    4. Have you travelled outside of Canada in the past 14 days? YesNo
    5. Have you had close contact with a probable case of COVID-19? YesNo

    I verify that the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic.

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