screening

Self-Assessment Screening Form

This screening tool is based on the latest COVID-19 case definitions and the Coronavirus disease (COVID-19) situation reports published by the World Health Organization.

Please answer all the questions honestly to the best of your ability.

The screening result is not equivalent to a confirmed diagnosis of COVID-19.

Please ensure you receive a confirmation that your form was submitted, if not, please go back and answer ALL the questions.

Name*

First Last

Date of Birth*

Phone*

Please enter the best phone number to reach you at in case we need to contact you about your screening form.

1. In the past 14 days, have you been required to quarantine as a result of travel outside of Canada?*

Yes
No
Unsure

2. In the last 5 days (if fully vaccinated) or 10 days (if unvaccinated), have you tested positive for COVID-19?*

Yes
No
Unsure

3. In the last 5 days (if fully vaccinated) or 10 days (if unvaccinated), have you come into contact with a COVID positive person?*

Yes
No
Unsure

4. Do you have any of the following UNEXPLAINED or WORSTENING symptoms:*

5. Over 70: Are you experiencing any of the following symptoms?*

Select All
Delirium
Unexplained or increased number of falls
Acute functional decline
Worsening of chronic conditions

I attest to the above information to be truthful.

Signature*

Patient/Parent/Guardian

Date*

Have you answered all the questions?

Yes (Select to be able to submit form)

If you do not receive a confirmation, go back, and see which questions you missed.

You have answered YES to one or more questions:

You have screened COVID-19 Positive. This is not a diagnosis.

Please follow up with your family doctor on your symptoms.

Alternatively, call Telehealth Ontario at 1-866-797-0000.

If you are experiencing a dental emergency, we will be able to treat you on an emergency basis. Please call the office at 613-482-8118 or e-mail us at info@limogesdentalcentre.com

COVID-19 Screening Questionnaire

Self-Assessment Screening Form

You have answered YES to one or more questions:

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