Baseline Dental Centre | COVID-19 Screening Questionaire
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COVID-19 Screening Questionaire

Medical History For the Screening Questionnaire, please fill out the boxes if applicable. If not please leave unchecked. If none apply, please check none of the above.


For patient 65 years or older, are you experiencing any of the following symptoms: unexplained or increased number of falls, acute functional decline or worsening of chronic conditions. lf response to all screening questions is checked non of the above, COVID screen negative. lf response to any screen questions is questions is checked, COVID screen positive.