Yonge and York Mills Dental Centre

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COVID-19 -- Pre-Screen Form

Name *

Email address *

Have you had close contact with anyone with acute respiratory Illness or traveled outside of Canada in the past 14 days? *

Yes

Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19? *

Yes

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

Are you 70 years of age or older AND experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? *

Yes

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