COVID-19 Screening Westmore

    Full Name:

    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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