COVID-19 Pre-Screening Questionnaire

The Ministry of Health requires all patients to complete this COVID-19 pre-screening questionnaire. All information is strictly private and is protected by doctor-patient confidentiality. The periodontist will review the questions and explain any that you do not understand.

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 non-emergent 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.

Screening form questions based on the Ministry of Health Self-Assessment Screening Tool 

COVID-19 Pre-Screening Questionnaire
*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.
*Do not select any of the above if 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).