Covid-19 Screening Form

Use this form to screen patients before their appointment

Staff screener

Patient Name:

Date of screening

Have the patient answer the following questions.

Screening Questions

Q1. Are you immunocompromised and/or live in a highest-risk congregate care setting?

Yes

Q2: Do you have any of these symptoms? Choose any or all that are new, worsening
and not related to other known causes or conditions.2
• 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

Yes

Q3: 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?

Yes

Q4: 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?

Yes

Any “YES” response (other than Q1) must be discussed with the managing dentist immediately. Symptomatic patients OR those with a positive COVID-19 test must only be seen in-person for urgent or emergent care: Non-urgent or nonemergent care must be deferred.
Based on results:
Immunocompromised individuals that have symptoms of COVID-19 or test positive for COVID-19 should stay
home (self-isolate) for 10 days and until:
• symptoms have been improving for at least 24 hours (or 48 hours if you had nausea, vomiting and/or diarrhea) and
• there’s no fever and
• you do not develop any additional symptoms.
Non-immunocompromised individuals that have symptoms of COVID-19 or test positive for COVID-19 should
stay home (self-isolate) until symptoms have been improving for at least 24 hours (or 48 hours if you had nausea, vomiting and/or
diarrhea) and
• there’s no fever and
• you do not develop any additional symptoms.

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.
Highest-risk congregate care setting include, for example, long-term care home, retirement home, employer-provided living setting
for International Agriculture Workers, hospital school, Education and Community Partnership Program.
2 Select “No” if all of these apply:
• you do not have a fever, and
• your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea)