Screening Questionnaire for Orthodontic appointment with Dr. Allyson Bourke
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Patient name *
Does the patient have a fever or have you/they felt hot or feverish recently (the last 14 days)? *
Required
Do you have shortness of breath or other difficulties breathing, new onset of cough, worsening of chronic cough? *
Required
Do you have any of the following symptoms;  sore throat, difficulty swallowing, decrease or loss of sense of taste or smell, chills, headaches, unexplained fatigue/malaise/muscle aches, nausea/vomiting, diarrhea, abdominal pain, pink eye,  or runny nose/nasal congestion that is not allergy related? *
Required
Has the patient tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE within the past 10 days? *
Required
Has the patient travelled outside of Ontario or had close contact with anyone that has travelled outside of Ontario in the past 14 days? *
Required
Has the patient been directed by a health care provider including public health official to isolate? *
Required
Have you read the information below? *
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