Patient First & Last Name



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Have you or anyone you have close contact with had acute respiratory illness or has travelled outside of Ontario in the last 14 days?

Yes

No


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Have you or anyone you have close contact with been diagnosed with a confirmed case of COVID-19?

Yes

No


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Do you have any of the following:
. Fever
. Runny nose
. New onset of cough or worsening chronic cough
. Shortness of breath or difficulty breathing
. Sore throat or difficulty swallowing
. Decrease/loss of sense of taste or smell


Yes

No


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Do you have any of the following:
. Chills
. Headaches
. Nasal congestion without other known cause
. Unexplained fatigue/malaise
. Muscle aches
. Nausea/vomiting
. Diarrhea/abdominal pain
. Post-nasal drip/sinus congestion


Yes

No


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Do you have any of the following:
. Pink eye/conjuctivitis
. Seasonal allergies

Yes

No


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Work History-Patient
. How many people are at your workplace?
. What do you do for a living?
. Do you social distance at work?
. When was the last time you were at work?
. Is anyone in your workplace sick or diagnosed with COVID-19?




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Work History-Patient
. What precautions is your workplace utilizing to keep you protected?
. When were you last out in public?




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Work History-Spouse:
. How many people in their workplace?
. What do they do for a living?
. Do they social distant at work?
. When was the last time they were at work?
. Is anyone at their workplace sick or diagnosed with COVID-19?




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Work History-Spouse:
. What precautions are they taking to keep them protected?
. When were they last out in public?




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Work History-Other Family/Household members:
. How many people in their workplace?
. What do they do for a living?
. Do they social distant at work?
. When was the last time they were at work?




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Work History-Other Family/Household members:
. Is anyone at their workplace sick or diagnosed with COVID-19?
. What precautions are they taking to keep them protected?
. When were they last out in public?




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I attest this is a true and accurate representation of my recent history in the time of COVID-19.

I Agree

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I understand that Beamsville Dental only gathers this information to help keep me, my family, their staff, and the community safe and it will not be used in any other manner.

I Agree

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Confirm your email address:

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