JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Smile Care Dental COVID Patient Self Screening
As per Public Health Guidelines MASKS ARE OPTIONAL
.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Email
*
Your answer
Phone Number
*
Your answer
1. Are you fully vaccinated against COVID-19 and/ or aged 11 or younger? ( The answer to this question will not impact your ability to access dental care)
*
Yes
No
Unsure/ Maybe/ Prefer not to answer
2. Are you currently experiencing: severe difficulty breathing, severe chest pain, feeling confused/ unsure where you are, losing consciousness?
*
Yes
No
Unsure/ Maybe
3. In the last 14 days, have you travelled outside of Canada? ( select "No" If exempt from federal quarantine requirements as directed by the border agent at your point of entry )
*
Yes
No
Unsure/ Maybe
4. In the last 5 days have you experienced any of these symptoms? ( Choose any/all that are new, worsening, and NOT related to other known causes or conditions you already have.)
*
Fever and/or chills (Temperature of 37.8 degrees Celsius or higher)
Cough (Continuous, more than usual, making a whistling noise when breathing)
Shortness of breath (Out of breath, unable to breathe deeply)
Decrease/ loss of taste or smell
Muscle aches/joint pain (Unusual, long-lasting)
Extreme tiredness ( Unusual fatigue, lack of energy)
Sore throat ( Painful or difficulty swallowing)
Runny or stuffy/congested nose
Headache ( New, unusual, long-lasting)
Nausea, vomiting and/or diarrhea
NONE OF THE ABOVE
Required
5. Do you live with someone who is currently isolating because of a positive COVID-19 test OR you live with someone who is currently isolating because of COVID-19 symptoms OR you live with someone who is isolating while waiting for COVID-19 test results?
Yes
No
Unsure/ Maybe
Clear selection
6. In the last 5 days, have you tested positive on a rapid antigen test, molecular test, or home-based self-testing kit?
Yes
No
Unsure/ Maybe
Clear selection
7. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
Yes
No
Unsure/ Maybe
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of SMILE CARE DENTAL OFFICE.
Report Abuse
Forms
