Patient Screening Form

Patient Name *

1. Have you tested positive for COVID-19 in the past 14 days and not been cleared by Public Health to end self-isolation? *

Yes

No

2. Have you been in contact with anyone with confirmed COVID-19 in the past 14 days AND been advised to self-isolate? *

Yes

No

3. Do you have, or have you had within the past 14 days, any of the following symptoms:

Fever above (38 degrees celsius) or feeling hot, chills/feverish *

Yes

No

Shortness of breath or other difficulties breathing *

Yes

No

Cough or worsening of a chronic cough *

Yes

No

Flu-like symptoms such as stomach upset, diarrhea, headache, fatigue or sore throat *

Yes

No

Recent alteration or loss of taste or smell *

Yes

No

Any new, unusual symptoms, e.g., feeling unwell, or sudden onset of runny nose *

Yes

No

4. Have you been in contact with anyone with any of the above symptoms of possible COVID-19 in the past 14 days AND been advised to self-isolate? *

Yes

No

5. If you have conditions or comorbidities that may make you more vulnerable to COVID-19 that you would like to share, please do so here:

6. Have you traveled in the past 14 days outside of the province and been advised to self-isolate based on current provincial restrictions on travel to Nova Scotia, and completion of the Nova Scotia Safe Check-in form? *

Yes

No

7. Have you traveled in the past 14 days outside of the country and been advised to self-isolate based on current federal government restrictions on travel into Canada?

Yes

No

8. Have you been to any location identified by NS Public Health Alert regarding possible exposures and been instructed to self-isolate and/or be tested for COVID-19? (Use the link below to view the updated list)

Yes

No

Use this link to view the updated information in regards:
https://novascotia.ca/coronavirus/alerts-notices/#possible-exposures

"YES" responses to any of these questions would indicate the need for a deeper discussion with the dentist before proceeding with treatment.

9. Are you fully vaccinated against COVID-19? Fully vaccinated means that it has been at least 14 days since you received the second dose of the Pfizer, Moderna, or AstraZeneca COVID-19 vaccine or the Janssen COVID-19 vaccine.

Yes

No

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COVID-19 Patient Screening