Patient Wellness Screening – youngdentistry.ca

Name *

First

Last

Email *

Are you unvaccinated against COVID-19 (ie. you have NOT had your final/second shot or you have had your second shot less than 14 days ago)? *

Have you traveled outside of Canada in the past 14 days? *

Have you tested positive for COVID-19 in the past 10 days or told you should be isolating? *

Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE in the last 14 days? *

Fever over 38°C (100.4°F) or chills? *

New onset of cough? *

Worsening Chronic cough? *

Shortness of breath or other difficulties breathing? *

Decrease or loss of taste or smell? *

If adult >18 years of age: Unexplained fatigue/malaise/muscle aches (myalgias)? *

If child <18 years of age: nausea, vomiting, diarrhea. *