(902) 757-2583
7859 Hwy 14,
Brooklyn,
NS
B0N 2A0
CA
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COVID-19 Patient Screening
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Please answer the following questions to ensure you are COVID-19 symptom free.
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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(902) 757-2583