Willowdale Dental Group - Brandon Gate    Back to Forms

Patient Pre-Screening Form

4025 Brandon Gate Drive, Mississauga, ON, L4T 3Z9      905-673-6565

Full Name:
E-mail:
YesNo
Have you had close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?
Do you have a confirmed case of Covid19 of had close contact with a confirmed case of Covid-19?

Do you have any of the following symptoms?

YesNo
Fever
New Onset of Cough
Worsening Chronic Cough
Shortness of Breath
Difficulty Breathing
Sore throat
Difficulty Swallowing
Decrease or loss of sense of taste of smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal cramps (of unknown origin)
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause

If you are over the age of 70, are you experiencing any of the following symptoms:

YesNoN/A
Delirium
Unexplained or increased number of falls
Acute functional decline
Worsening of chronic conditions

Patient (Guardian) Signature