Appointment Health Screening
Thank you for completing this form honestly and protecting the health of our staff and other patients. If more than one person is attending, for example a child and parent, or multiple patient appointments you can use one form, but answer for all individuals.
1. Patient Name
If more than one person is attending the appointment, please enter names and the reason . Note we only allow one additional caregiver.
Have you traveled outside of Canada in the last 14 days?
Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
Do you currently have any of the following symptoms?
New onset of cough
Worsening chronic cough
Shortness of breath
Decrease or loss of sense of taste or smell
Unexplained fatigue,muscle aches or malaise
Nausea/vomiting,diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause
Please provide details on the symptoms.
Are you 70 years of age or older and are you experiencing any of the followingsymptoms?
Unexplained or increased number of falls
Acute functional decline
Worsening of chronic conditions
Have you come into contact with anyone that has any of the above symptoms in the last two weeks, or contact with anyone suspected or diagnosed of having COVID-19 in the last 2 weeks?
Please provide details on the contact, including whether your contact was because of your job and whether you had appropriate PPE and precautions (i.e. you are a healthcare provider or other 'front line' work).
Have you been tested for COVID-19?
Please provide the date of the test, test result and reason for testing.
Should be Empty: