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PATIENT SCREENING FORM - RECALL MAX

Screening Questions

In-Office

Do you have a fever or have felt hot or feverish anytime in the last 10 days

Yes
No

Do you have any of these symptoms: New or worsening Cough? New or worsening shortness of breath? Difficulty Yes / No Yes / No Breathing? Sore throat or painful swallowing? Runny nose?

Yes
No

Have you experienced a recent loss of taste or smell?

Yes
No

Have you been in contact with any confirmed COVID-19 Positive people, or persons self-isolating because of a determined risk for COVID-19

Yes
No

Have you returned from travel outside of Canada in the Last 14 days?

Yes
No

Have you returned from travel within Canada from a location Known affected with COVID-19 in the last 14 days?

Yes
No

Is your workplace considered high risk?

Yes
No

Are you over the age of 65?

Yes
No

Do you have any of the following Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?

Yes
No

201 13th Ave SE Calgary AB., T2G 1Z8

PH 403-228-3088 FAX 403-460-3334

www.nueradental.com

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