Patient Screening Form

Covid-19 Screening Form

Waterloo Emergency Dental Centre

258 King Street North, Unit #7,
Waterloo, Ontario, Canada N2J 2Y9
Phone: (519) 883-0505
Today's Date*
DD slash MM slash YYYY
Patient Name*
First Middle Last
Date of Birth*

Day
Month
Year
Who is Filling Out This Form?*
Please Specify
Q1. Are you immunocompromised?*

Factors such as old age, diabetes and end-stage renal disease are generally not considered immunocompromised. Examples of being immunocompromised include individuals:
• undergoing cancer chemotherapy
• with untreated HIV infection with CD4 T lymphocyte count less than 200
• with combined primary immunodeficiency disorder
• on prednisone medication - more than 20 mg per day (or equivalent) for more than 14 days
• on other immune suppressive medications.
- YES
- NO
Q2: Do you have any of these symptoms? Choose any or all that are new, worsening and not related to other known causes or conditions*

• Fever and/or chills
• Extreme tiredness Cough or barking cough
• Sore throat Shortness of breath
• Runny or stuffy/congested nose Decrease or loss of taste or smell
• Headache
• Muscle aches/joint pain
• Nausea, vomiting and/or diarrhea
• Abdominal pain
• Pink eye

Select “No” if all of these apply:
• you do not have a fever, and
• your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea)
- YES
- NO
Q3: Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other government authority) that you should currently be quarantining, isolating or staying at home?*
- YES
- NO
Q4: In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit?*
- YES
- NO
Any “yes” response (other than Q1) must be discussed with the managing dentist immediately.

When you arrive at the office, you will be asked to sanitize your hands.
Patient Signature (Type Your Full Name)*
Date*
DD slash MM slash YYYY

Covid-19 Screening Form

Waterloo Emergency Dental Centre