Patient Screening Form

Patient Screening Form

Waterloo Emergency Dental Centre

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

DD
MM
YYYY
Age*
Home Phone
Cell Phone*
Email*
Work Phone
Extension Number
Date of Appointment*
Date Format: DD slash MM slash YYYY
Time*

: HH

MM
Screening Questions Pre-Screen
Have you had contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?*
- YES
- NO
Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?*
- YES
- NO
Do you have any of the following symptoms: Fever, New onset of cough, Worsening chronic cough, Shortness of breath, Difficulty breathing, Sore throat, Difficulty swallowing, Decrease or loss of sense of taste or smell, Chills, Headaches, Unexplained fatigue/malaise/muscle aches(myalgias), Nausea/vomiting, diarrhea, abdominal pain, Pink eye (conjunctivitis), Runny nose/ nasal congestion without other known cause?*
- YES
- NO
Are you 70 years of age or older, experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?*
- YES
- NO
Patient Signature (Write your Name)*
Date*
Date Format: DD slash MM slash YYYY
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Waterloo Emergency Dental Centre