COVID-19 Screening Questionnaire

All clients will be pre-screened prior to scheduling an appointment in the CNIH Dental Clinic. An appointment cannot be scheduled if the client has not been reached in advance to be pre-screened. The following questions1 will be asked by clinical reception:

YesNo

YesNo

YesNo

YesNo

  • Fever
  • New onset of cough
  • Worsening chronic cough
  • Shortness of breath
  • Difficulty breathing
  • Sore throat
  • Difficulty swallowing
  • Decrease or loss of sense of taste or smell
  • Chills
  • Headaches
  • Unexplained fatigue/malaise/muscle aches (myalgias)
  • Nausea/vomiting, diarrhea, abdominal pain
  • Pink eye (conjunctivitis)
  • Runny nose/nasal congestion without other known cause

YesNo


If all questions are answered “no,” they are considered “COVID screen negative” and can enter the facility. If any question is answered “yes,” they are considered “COVID screen positive” and cannot enter the facility until they meet the criteria for “COVID screen negative.”

This is a living document and CNIH reserves the right to make amendments as needed.
2. “COVID-19 Patient Screening Guidance Document.” (2020). Ministry of Health. Retrieved from
http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_patient_screening_guidance.pdf