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Louvre Dental in Paris & Brantford | Your Paris & Brantford Dentist
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Patient Informed Consent Agreement
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(519) 442-0132
Make Appointment
COVID Screening Questionnaire
COUGH or BARKING COUGH (Croup) Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have:
(Required)
YES
NO
FEVER and/or CHILLS Temperature of 37.8°C/ 100°F or higher
(Required)
YES
NO
SHORTNESS OF BREATH Not related to asthma or other known causes or conditions you already have:
(Required)
YES
NO
SORE THROAT Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have:
(Required)
YES
NO
DIFFICULTY SWALLOWING Painful swallowing not related to other known causes or conditions you may already have:
(Required)
YES
NO
DECREASE or LOSS OF SMELL or TASTE Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have:
(Required)
YES
NO
RUNNY or STUFFY/CONGESTED NOSE Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have:
(Required)
YES
NO
HEADACHE Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have):
(Required)
YES
NO
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:
(Required)
YES
NO
MUSCLE ACHES/JOINT PAIN Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have):
(Required)
YES
NO
FATIGUE Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have):
(Required)
YES
NO
FALLING DOWN OFTEN For elder people
(Required)
YES
NO
2. Has a doctor, healthcare provider, or public health unit told you that you should currently be isolating (stay at home)?
(Required)
YES
NO
3. In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?
(Required)
YES
NO
4. In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?
(Required)
YES
NO
5. In the last 14 days, have you or anyone in your home, travelled outside of Canada?
(Required)
YES
NO
6. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?
(Required)
YES
NO
Temperature when arrived for appointment:
(Required)
Patient Name:
(Required)
First
Last
Signature
(Required)
Relation to patient if needed:
Date
(Required)
MM slash DD slash YYYY