In Office Patient Screening Form

In Office Patient Screening Form

Lancaster Dental

493 Lancaster Street West, Suite #206
Kitchener, ON N2K 1L8
Phone: 519-578-9670
Staff Screener:*
Date:*
DD slash MM slash YYYY
Patient Name:*
First Middle Last
Age:*
Patient Temperature:*
Mask provided to Patient:*
Why wasn't the maks provided?
In Office Screening Questions
Have you had contact with anyone with acute respiratory illness or travelled outside of Canada in the past 14 days?*
- YES
- NO
Have you ever tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE (facemask)?*
- YES
- NO
When?*
DD slash MM slash YYYY
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 chronic conditions?
- YES
- NO
CAPTCHA

Lancaster Dental