COVID 19 Patient Screening Form
Patient Name
*
First Name
Last Name
Who Answered
*
Patient
Other
Specify
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Screening Questions
Have you had close contact with anyone with acute respiratory illness (without PPE) or traveled outside of Ontario in the past 14 days?
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Yes
No
Do you have a confirmed case of COVID-19 or had a close contact with a confirmed case of COVID-19 (without PPE)?
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Yes
No
Do you have any of the following symptoms
Fever
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Yes
No
Cough
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Yes
No
Body aches
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Yes
No
Headaches
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Yes
No
Sore Throat
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Yes
No
Loss of energy/fatigue
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Yes
No
Runny nose or stuffy nose
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Yes
No
Shortness of breath
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Yes
No
Are you 70 years or older?
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Yes
No
Are you experiencing any of the following symptoms?
Delirium
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Yes
No
Falls
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Yes
No
Functional decline
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Yes
No
Signature
*
Clear
Name
*
First Name
Last Name
Date
*
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Month
-
Day
Year
Date
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