Your First And Last Name (required)
COVID-19 Risk Factor Screening (please check all that apply)
I have had close contact with someone with acute respiratory illness in the past 14 days yesno
I have a confirmed case of COVID-19 or have had close contact with a person with a confirmed case of COVID-19 without wearing the appropriate personal protective equipment (PPE) yesno
I have traveled outside of CANADA in the past 14 days yesno
COVID-19 Symptoms Screening (please check all that apply to your or to any member of your household)
Fever yesno
Chills yesno
Cough that's new or worsening (continuous, more than usual) yesno
Barking cough, making a whistling noise when breathing yesno
Shortness of breath (out of breath, unable to breath deeply) yesno
Sore throat yesno
Difficulty swallowing yesno
Runny, stuff, congested nose (not related to seasonal allergies or other known causes or conditions) yesno
Lost sense of taste or smell yesno
Pink eye (conjunctivitis) yesno
Headache that's unusual or long lasting yesno
Digestive issues (nausea/vomiting, diarrhea, stomach pain) yesno
Muscle aches yesno
Extreme tiredness that's unusual (fatigue, lack of energy) yesno
Falling down often yesno
For young children and infants: sluggishness or lack of appetite yesnoN/A
If you or someone in your household is 70 years of age or older, are you (they) experiencing any of the following symptoms:
Delirium yesnoN/A
Unexplained or increased number of falls yesnoN/A
Acute functional decline yesnoN/A
Worsening or chronic symptoms yesnoN/A
Thank you for completing this COVID-19 screening prior to your appointment. We appreciate your help and cooperation.
