COVID 19 Patient Screening Form
Patient Name
*
First Name
Last Name
Who Answered
*
Patient
Other
Specify
*
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?
*
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)?
*
Yes
No
Are you fully vaccinated against COVID-19
*
Yes
No
Prefer not to disclose
Do you have any of the following symptoms
Fever
*
Yes
No
Cough
*
Yes
No
Body aches
*
Yes
No
Headaches
*
Yes
No
Sore Throat
*
Yes
No
Loss of energy/fatigue
*
Yes
No
Runny nose or stuffy nose
*
Yes
No
Shortness of breath
*
Yes
No
Are you 70 years or older?
*
Yes
No
None of the above symptoms
Are you experiencing any of the following symptoms?
Delirium
*
Yes
No
Falls
*
Yes
No
Functional decline
*
Yes
No
Signature
*
Clear
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit Form
Should be Empty: