PATIENT - COVID-19 SCREENING FORM

1

APPOINTMENT DATE* This field is required.

Date

2

PATIENT NAME* This field is required.

First Name

Last Name

3

PHONE NUMBER* This field is required.

Please enter a valid phone number.

4

Do you or anyone in your household have any of the following symptoms?* This field is required.

Fever and/or Chills

Shortness of Breath

New Onset of Cough or Worsening Chronic Cough

Decrease of loss of taste or smell

If adult > 18 yrs of age: unexplained fatigue/lethargy/malaise/muscle aches (myalgias)

If child < 18 yrs of age: nausea/vomiting/diarrhea

None of the above

5

Have you tested positive for COVID-19 or been exposed to a positive case in the past 10 days * This field is required.

YESNO

6

Has anyone (the Health Unit or close contacts) told you that you should be isolating? * This field is required.

YESNO

7

Did you receive your second vaccination dose more than 14 days ago? * This field is required.*A fully immunized individual is defined as any individual >14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series (i.e. Johnson and Johnson).

YESNO

8

Have you travelled outside of Canada in the past 14 days? * This field is required.

YESNO