AYLMER FAMILY DENTAL COVID-19 PRE-SCREENING FORM COVID-19 In-Office Screening FormPatient Name:* First Last Date of Birth: Month Day Year 1. Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? yes/no* Yes No 2. Have you travelled outside of Canada in the past 14 days?* Yes No 3. Have you had close contact with anyone self-isolating because of a determined risk of COVID-19?* Yes No 4. 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 or muscle aches nausea/vomiting, diarrhea, abdominal pain pink eye runny nose or nasal congestion without other known cause none of the above 5. Are you 70 years of age or older?* Yes No Are you experiencing any of the following symptoms:* Delirium Unexplained or increased number of falls Acute functional decline Worsening of chronic conditions None of the above * I verify that the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have my dental treatment completed during the COVID-19 pandemic. * I will notify Aylmer Family Dental shoud I develop any of the above symptoms prior to my scheduled appointment. Signature*CommentsThis field is for validation purposes and should be left unchanged.