Patient Screening Form

MM slash DD slash YYYY
Have the patient answer the following questions.
Q1. Are you immunocompromised?
  • Fever and/or chills tiredness Cough or barking cough Shortness of breath nose Decrease or loss of taste or smell
  • Muscle aches/joint pain Extreme
  • Sore throat
  • Runny or stuffy/congested
  • Headache
  • Nausea, vomiting and/or diarrhea
  • Abdominal pain
  • Pink eye
Question 2
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?
Q4. In the last lO 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?
  • Sanitize their hands
  • Have their temperature taken (depending on the dental office*s policies).
  • 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.
  • you do not have a fever, and
  • your sympLoms have been improving for 24 hours (4B hours if you have nausea, vomiting, and/or diarrhea)