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
Age*
Date of Appointment*
DD slash MM slash YYYY
1. Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions.*
- YES
- NO

Fever and/or chills	Temperature of 37.8 degrees Celsius/100 F or higher.
Cough or barking cough (croup)	Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have.
Shortness of breath	Shortness of breath Not related to asthma or other known causes or conditions you already have.
Sore throat	Sore throat Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have.
Difficulty swallowing	Difficulty swallowing Painful swallowing (not related to other known causes or conditions you already have.)
Decrease or loss of smell or taste	Decrease or loss of smell or taste Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have.
Pink eye	Pink eye Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have.)
Runny or stuffy/congested nose	Runny or stuffy/congested nose Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have.
Headache	Headache Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have.) If you received a COVID-19 vaccination in the last 48 hours and are experiencing a mild headache that only began after vaccination, select “No.”
Digestive issues like nausea/vomiting, diarrhea, stomach pain	Digestive issues like nausea/ vomiting, diarrhea, stomach pain. Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have.
Muscle aches/joint pain	Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have.) If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild muscle aches/joint pain that only began after vaccination, select “No.”
Fatigue	Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have. If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select “No.”
Falling down often	For older people.

2. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?*
This can be because of an outbreak or contact tracing.
- YES
- NO
3. In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit?*
If you have since tested negative on a lab-based PCR test, select “No.
- YES
- NO
4. In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?*
If you are fully vaccinated* and have not been advised to self-isolate by public health, select “No”.
- YES
- NO
5. In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?*
If you are fully vaccinated and/or have already gone for a test and got a negative result, select "No." ** Fully vaccinated is defined as an individual ≥14 days after receiving their second dose of a two-dose COVID19 vaccine series or their first dose of a one-dose COVID-19 vaccine series.
- YES
- NO
6. . In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?*
If you are not fully vaccinated and you live with someone who travelled outside of Canada, see Notes below.
- YES
- NO
7. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?*
If you are fully vaccinated, select “No.” If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”
- YES
- NO
Note: Effective July 5, 2021, fully vaccinated Canadians may be exempt from post-travel COVID-19 quarantine restrictions. For those individuals who are not fully vaccinated AND either 1) live with an individual who has recently traveled outside of Canada OR 2) live with an individual who is self-isolating due to a high-risk exposure: These individuals are permitted to attend work, but they are required to stay home except for essential reasons for the duration of the contact’s isolation period. Essential reasons include: attending school/child care/work and essential errands such as, obtaining groceries, attending medical appointments or picking up prescriptions.
Patient Signature (Write your Name)*
Date*
DD slash MM slash YYYY

Covid-19 Screening Form

Waterloo Emergency Dental Centre