COVID-19 Form | Gutenberg Certs
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Updated vers 4.0.  11-June-2020 as per Ontario Ministry of Health

This screening tool is based on the latest COVID-19 case definitions and the Coronavirus
disease (COVID-2019) situation reports published by the World Health Organization.  Ensuring all health providers are following the same screening protocol will help ensure consistency whendealing with suspected or confirmed cases of COVID-19. 

Ontario - Ministry of Health
COVID-19 Screening Form

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COVID-19 Daily Self Declaration

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Nika Dental Center

I attest the following:

  • I did not travel outside of Canada in the past 14 days 

  • I did not tested  positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE 


 I am well today and do NOT have any of the following symptoms

  • Fever (higher than 37.5 C)

  • New onset of cough

  • Worsening chronic cough

  • Shortness of breath

  • Difficulty breathing

  • Sore throat

  • Difficulty swallowing

  • Decrease of loss of sense of taste or smell

  • Chills

  • Headaches

  • Unexplained fatigue/malaise/muscle aches (myalgias)

  • Nausea/vomiting, diarrhea, abdominal pain Pink eye (conjunctivitis)

  • Runny nose or nasal congestion without other known cause 

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If I am 70 years of age or older, I am NOT experiencing any of the following symptoms:

  • Delirium

  • Unexplained or increased number of falls

  • Acute functional decline

  • Worsening of chronic conditions

Thank You for submitting. You will receive an email shortly.

Submit
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