Covid-19 Screening Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Questions adapted from the Ministry of Health Ontario. Please answer Yes or No.
For questions on how to complete the questionnaire: call 905-775-7377 or info@arbodentalcare.com
These questions are not a substitute for a medical diagnosis. If you are experiencing any of the following symptoms, please contact your family physician, an assessment centre or call Telehealth Ontario 1-866-797-0007, or if it is a medical emergency call 911.

Email *

First and Last Name *

First and Last Name of Family Members Today

Best phone number to contact you: *

1. Have you had close contact with anyone with acute respiratory illness or travelled outside Ontario in the past 14 days? *

Yes

Required

2. Have you had a confirmed test result for COVID-19, or had close contact with a confirmed case of COVID-19 in the past 14 days? *

Yes

Required

3. 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/muslce aches (myalgias), Nausea/vomiting, diarrhea, abdominal pain Pink eye (conjunctivitis), Runny nose/nasal congestion without other known cause *

Yes

Required

If you are 70 years of age or older, are you experiencing any of the following symptoms: Delirium Unexplained or increased number of falls Acute functional decline Worsening chronic conditions *

Yes

Required

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Arbo Dental. Report Abuse

Forms