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Patient Covid Questionnaire

Patient Info
Patient Name*
Patient Age*
Screening Questions
Parent/Legal Guardian may fill out this section
1. Do you have a fever (greater than 38°C) or feverish chills, sweats, muscle aches, light-headedness?*
- Yes
- No
2. Do you have any of these symptoms: New or worsening cough? Sore throat (difficulty swallowing)? New or worsening runny nose? New or worsening shortness of breath? New or worsening headache?*
- Yes
- No
3. Have you been in close personal contact, without PPE, with a suspected or confirmed COVID-19 patient within the past 2 weeks?*
- Yes
- No
4. Have you travelled outside of Atlantic Canada (Nova Scotia, New Brunswick, Prince Edward Island and Newfoundland and Labrador) by air, car, bus or otherwise in the past 2 weeks?*
- Yes
- No
Patient Vulnerability
Useful in patient scheduling
5. Do you have any of the following medical conditions which would put you in a high-risk category:
- Diabetes
- Cardiovascular Disease
- Hypertension
- Lung Diseases (including moderate to severe asthma)
- Immunocompromised
- Active Malignancy
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Contact Us

902-857-1755
902-857-1757
902-200-7232 (Text)
PO Box 40
11 Hwy 329 Hubbards,
Nova Scotia, B0J 1T0

Office Hours

Monday: 9:00 - 4:00
Tuesday: 10:00 - 7:00
Wednesday: 9:00 - 5:00
Thursday: 8:15 - 4:00

Office Address

Hubbards Family Dental Clinic
Pharmasave Medical Complex
11 Highway 329
Hubbards, Nova Scotia B0J 1T0

Contact Us

Name*
Email*
Comment or question below.*
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