Patient Wellness Screening – youngdentistry.ca

Name *

First

Last

Email *

Are you immunocompromised? Factors such as old age, diabetes, and end-stage renal disease are generally not considered immunocompromised. Examples of being immunocompromised include individuals: • undergoing cancer chemotherapy • with untreated HIV infection with CD4 T lymphocyte count less than 200 • with combined primary immunodeficiency disorder • on prednisone medication - more than 20 mg per day (or equivalent) for more than 14 days • on other immune suppressive medications. *

Do you have any of these symptoms? • Fever and/or chills • Cough or barking cough • Shortness of breath • Decrease or loss of taste or smell • Muscle aches/joint pain • Extreme tiredness • Sore throat • Runny or stuffy/congested nose • Headache • Nausea, vomiting and/or diarrhea • Abdominal pain • Pink eye NB- If you do not have a fever and your other symptoms are have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea), select "No". If the symptoms are related to a known non-COVID cause or condition, select "No". *

Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other government authority) that you should currently be quarantining, isolating or staying at home? *

In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit? *