COVID-19 Screening Westmore

Full Name:
Date:

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

• Fever or chillsYesNo

• Difficulty breathing or shortness of breathYesNo

• CoughYesNo

• Sore throat, trouble swallowing YesNo

• Runny nose/stuffy nose or nasal congestionYesNo

• Decrease or loss of smell or tasteYesNo

• Nausea, vomiting, diarrhea, abdominal painYesNo

• 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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