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Health History Form
Dental Hygiene & Prevention
Hospital Based Treatment
Root Canal Therapy
1. Have you had a positive COVID-19 test in the past 10 days or are awaiting a test result?
2. Are you experiencing cold, flu or COVID-19-like symptoms, even mild ones?
• Symptoms include: fever, chills, cough, shortness of breath, sore throat and painful swallowing, stuffy or runny nose, loss of sense of smell, headache, muscle aches, fatigue or loss of appetite.
3. Are you currently required to isolate or quarantine due to COVID-19 ?
4. Did you provide care for, or have close contact with a person who has confirmed or suspected COVID-19?
** A close contact is defined as a person who: • Provided care for the individual, including healthcare workers, family members or other caregivers, or who had other similar close physical contact with the person without consistent and appropriate use of personal protective equipment • Lived with or otherwise had close prolonged contact (with 2 meters) with the person while the person was infectious • Had direct contact with infectious bodily fluids of the person (eg. Was coughed or sneezed on) while not wearing recommended personal protective equipment
I certify that the information submitted in this application is true and correct to the best of my knowledge.
If you are human, leave this field blank.
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