COVID-19 Screening Questionnaire

All clients will be pre-screened prior to scheduling an appointment in the CNIH Dental Clinic. An appointment cannot be scheduled if the client has not been reached in advance to be pre-screened. The following questions1 will be asked by clinical reception:

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1) Have you been in close contact with anyone who has had acute respiratory illness?
2) Have you travelled outside of Ontario within the last 14 days?
3) Have you been a confirmed case of COVID-19 or been in contact with a confirmed case of COVID-19?
4) Are you experiencing 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
5) For individuals over 70 years old: are you experiencing any of the following symptoms: confusion, dizziness, a sudden change in the ability to function or worsening of chronic conditions?

This is a living document and CNIH reserves the right to make amendments as needed.
2. “COVID-19 Patient Screening Guidance Document.” (2020). Ministry of Health. Retrieved from
http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_patient_screening_guidance.pdf

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