Covid 19 - Ministry of Health screening

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Please complete the following questions before coming in for your appointment.

Patient Name *

Date *

YYYY

Did the patient receive their final (or second) vaccination dose more than 14 days ago? *

Yes

Not Eligible

Does the patient have any of the following symptoms?• Fever and/or chills • New onset of cough or worsening chronic cough • Shortness of breath • Decrease or loss of sense of taste or smell • If adult >18 years of age: unexplained fatigue/lethargy/malaise/muscle aches(myalgias) • If child <18 years of age: nausea/vomiting, diarrhea *

Yes

Has the patient tested positive for COVID-19 in the past 10 days or have they been told they should be isolating? *

Yes

Only answer the next questions if the patient is not fully immunized (ie answered no or not eligilble to the first question)

Did the patient travel outside of Canada in the past 14 days?

Yes

Clear selection

Has the person had close contact with a confirmed case of COVID-19 ?

Yes

Clear selection

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This form was created inside of Midtown Orthodontics.