COVID Screening Questionnaire

Before your visit, please complete our COVID screening questionnaire so our Kitchener dental team can prepare for your appointment safely. This short COVID screening questionnaire helps us protect our patients and staff by identifying any symptoms or exposure risks in advance.

Filling out the COVID screening questionnaire takes just a minute and can be submitted online before you arrive at our office. If you have any questions about the COVID screening questionnaire or your upcoming appointment, please call our Kitchener office and our team will be happy to help.

COVID Screening Questionnaire

 COUGH or BARKING COUGH (Croup) Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have:(Required)

YES

NO

 FEVER and/or CHILLS Temperature of 37.8°C/ 100°F or higher(Required)

YES

NO

 SHORTNESS OF BREATH Not related to asthma or other known causes or conditions you already have:(Required)

YES

NO

 SORE THROAT Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have:(Required)

YES

NO

 DIFFICULTY SWALLOWING Painful swallowing not related to other known causes or conditions you may already have:(Required)

YES

NO

 DECREASE or LOSS OF SMELL or TASTE Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have:(Required)

YES

NO

 RUNNY or STUFFY/CONGESTED NOSE Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have:(Required)

YES

NO

 HEADACHE Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have):(Required)

YES

NO

 DIGESTIVE ISSUES LIKE NAUSEA/VOMITING, DIARRHEA, STOMACH PAIN Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have:(Required)

YES

NO

 MUSCLE ACHES/JOINT PAIN Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have):(Required)

YES

NO

 FATIGUE Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have):(Required)

YES

NO

 FALLING DOWN OFTEN For elder people(Required)

YES

NO

2. Has a doctor, healthcare provider, or public health unit told you that you should currently be isolating (stay at home)?(Required)

YES

NO

3. In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?(Required)

YES

NO

4. In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?(Required)

YES

NO

5. In the last 14 days, have you or anyone in your home, travelled outside of Canada?(Required)

YES

NO

6. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?(Required)

YES

NO

Temperature when arrived for appointment:

Patient Name:(Required)

First Last

Signature(Required)

Relation to patient if needed:

Date(Required)

MM slash DD slash YYYY

Why We Ask You to Complete This Questionnaire

Public health guidelines recommend that dental offices continue to screen patients before in-person visits. Our COVID screening questionnaire allows us to review your current health status, recent travel, and any possible symptoms so we can safely schedule your visit and keep our Kitchener clinic a safe environment for everyone.

Frequently Asked Questions

When should I complete the COVID screening questionnaire?
We recommend completing the questionnaire within 24 hours before your scheduled appointment at our Kitchener office.

Is my information kept confidential?
Yes. All responses to the COVID screening questionnaire are kept private and are used only to help our team prepare for your visit.

What happens if I answer yes to a symptom question?
Our team will contact you directly to discuss rescheduling options or any additional precautions needed before your visit.