All patients are required to complete the following questionnaire before their appointment and prior to commencing any recommended dental procedures. You will be rescreened upon entering the office. If you screen positive for covid-19 at any point, we will ask that you delay your visit by at least 14 days. Please submit your answers promptly. If no response is received 24hrs prior to your scheduled appointment we will attempt to contact you by phone. If we cannot reach you to complete this medical questionnaire your appointment will be cancelled.Patient First NamePatient Last NamePatient Date of Birth Date Format: MM slash DD slash YYYY Parents or Legal Guardians Name if Patient is under 18yrs:PhoneEmail 1. Have you (or the patient if a minor) tested positive for COVID-19 in the past month or are you waiting for results from COVID19 testing?YesNo2. Have you (or the patient if a minor) been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19 within the last 14 days?YesNo3. Have you (or the patient if a minor) or anyone in your household been advised by your physician or provincial health authority to self isolate or self quarantine due to a possible exposure to COVID-19 within the last 14 days?YesNo4. Have you or someone in your household returned from travel outside of Ontario in the past 14 days?YesNoIf you answered yes above, where did you travel to?5. Do you have any of the following symptoms? Check all that apply Fever (above 37.8 degrees Celsius or 100.04 degrees fahrenheit) New onset cough Worsening chronic cough Shortness of breath Difficulty breathing Sore throat Difficult swallowing Decrease or loss of sense of taste or smell Chills Headache Unexplained fatigue / malaise / muscle aches (myalgias)(malaise is a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify) Nausea / vomiting, diarrhea, abdominal pain Pink eye (conjunctivitis) Runny nose or nasal congestion without other known cause None of the above If you answered yes to any of the above symptoms, please explain if this is due to an existing condition:6. Do you (or the patient if a minor) have heart, lung or kidney disease, diabetes, are obese or have any auto-immune disorders?YesNoIf yes, please describe:7. If you are 70 years or age or older, are you experiencing any of the following symptoms?- Delirium - Unexplained or increased number of falls - Acute functional decline - Worsening of chronic conditionsYesNoDoes not apply to me8. Please indicate any changes in your medical history in the last year:9. List all current medications, including dosages:(If you are unsure, please provide your pharmacy telephone number here and we will request a list on your behalf) I confirm that I know there are categories of people who are considered to be at high risk. I understand the high-risk category factors are being 65 years of age or older, heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder. If I (or the patient I am completing this form for) are in one of these categories I have chosen to proceed with my (or the patients) appointment knowing the risk to my (or the patients) health if I (or the patient) develop COVID-19. I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand the federal and provincial governments have asked individuals to maintain social distancing of at least 2 metres (6 Feet) and I recognize it is not possible to maintain this distance while receiving dental treatment. I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have dental treatment completed during the COVID-19 pandemic. I consent to the statementsSignature of Patient or Parent/Guardian of minorFirst NameLast NameDate Date Format: MM slash DD slash YYYY