Lee Dental Patient Screening Form

    OFFICE USE ONLY 僅限辦公室使用

    Use this form to screen patients before their appointment and when they arrive for their appointment.
    Staff screener:   
    Patient Name:  
    Patient age:  
    Who answered:    
    Contact Method:    
    Identify yourself and explain the purpose of the call, which is to determine whether there are any special considerations for their dental appointment. Have the patient answer the following questions.

    PATIENT SCREENING QUESTIONS 病人篩查問題

    Patient Name*:  

    QUESTIONS ANSWERS*
    Is this form filled before the appointment or in the office?
    此表格是在預約之前或在辦公室中填寫?
    Have you had close contact with anyone with acute respiratory Illness travelled outside of Ontario in the past 14 days?
    你最近14天是否有出入過安省,或接觸過確診/疑似的新冠病人?
    Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?
    你是否被確診為新冠病毒患者或與確診者有近距離接觸?
    Do you have any of the following symptoms:
    是否有任何以下症狀:

    • Fever 發燒
    • cough 咳嗽
    • Shortness of breath/Difficulty breathing 呼吸困難
    • Sore throat 喉嚨痛
    • Difficulty swallowing 吞嚥困難
    • Decrease or loss of sense of taste or smell 下降/失去味覺或嗅覺
    • Chills 發冷
    • Headaches 頭痛
    • Unexplained fatigue/malaise/muscle aches (myalgias) 肌肉疼痛
    • Nausea/vomiting, diarrhea, abdominal pain, Pink eye (conjunctivitis) 反胃,嘔吐,腹瀉,腹痛,眼部充血
    • Runny nose/nasal congestion without other known cause 非過敏性鼻炎
    Are you 70 years of age or older, experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?
    年紀是否在70歲或以上並有精神錯亂,身體機能和免疫力下降的症狀?


    Patient Acknowledgement:

    COVID-19 Pandemic Dental Risk

    Please read the patient acknowledgement below, and initial or sign in all areas indicated.
    請仔細閱讀以下內容並在空白處簽名。

    Acknowledgement Initial*
    I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. For this reason, I understand that the federal and provincial authorities have recommended that Ontarians stay home and avoid close contact with other people when at all possible.
    我明白新冠病毒或稱COVID-19現在成為一種流行疾病,具有長時間的潛伏期和無症狀感染的表現。因此,我明白聯邦和省級政府建議安省居民留在家裡以避免與其他人近距離接觸。
    I understand the federal and provincial authorities have asked individuals to maintain social distancing of a least two (2) meters (six (6) feet) and recognize it is not possible to maintain this distance while receiving dental treatment.
    我明白雖然聯邦和省級政府呼籲至少2米(6尺)的社交距離,但是我接受牙醫治療的過程中不可能保持上述距離。

    I understand that oral surgery/dental procedures can create water and/or blood spray, which is one way that the novel coronavirus can spread. I understand that the ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the novel coronavirus.
    我明白牙科手術會產生的水或血液飛濺是傳播新冠病毒的一種介質,並且會在空氣中存活幾分鐘甚至幾個小時。
    I understand that due to the visits of other patients, the characteristics of the novel coronavirus, and the characteristics of dental procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in the dental office.
    我明白牙醫診所是個新冠病毒感染的高風險場所,而我的造訪會提高自我感染幾率。
    I confirm that I do NOT have any TWO OR MORE or the following symptoms of COVID-19: (i) fever, (ii) new or worsening cough, (iii) sore throat, (iv) runny nose or (v) headache.
    我確認本人並沒有兩種或以上的新冠病毒症狀:發燒、咳嗽、喉嚨痛、流鼻涕、頭痛。
    If I received COVID-19 test results in the past three (3) months, the last results I received were negative. If applicable, approximate date of test
    假如我3個月內曾接受過新冠病毒檢測,最後檢測結果是陰性。請提供檢測日期
    I confirm that I am not waiting for the results of a test for COVID-19.
    我確認我目前並沒有在等待新冠病毒的檢測結果。
    I confirm that this is not currently a period during which public health authorities required I self-isolate
    我確認我不是在衛生部門強制的自我隔離階段。


    checked *  I verify the information I have provided on this form is truthful and complete. I knowingly and willingly consent to have surgical/dental treatment completed during the COVID-19 pandemic. 我確認以上信息的真實性和完整性,並同意在新冠病毒大流行期間接受牙醫治療。

    Print Your Name*:       Date*: