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PATIENT - COVID-19 SCREENING FORM
Please fill out and submit this form to complete prescreening.
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1
APPOINTMENT DATE
*
This field is required.
-
Date
Year
Month
Day
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2
PATIENT NAME
*
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First Name
Last Name
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3
PHONE NUMBER
*
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Please enter a valid phone number.
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4
Are you a child (under 11 years old)?
*
This field is required.
YES
NO
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5
How many doses of the Covid-19 vaccine have you had?
*
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1 dose
2 doses
3 doses (1st booster)
4 doses (2nd booster)
None of the above
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6
Have you had any of the following symptoms in the past 5 days (vaccinated) or 10 days (partially vaccinated or unvaccinated)?
*
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Not related to a known existing condition.
Fever and/or chills
New or worsening cough
Loss of taste or smell
Shortness of breath
None of the above
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7
Have you experienced 2 or more of the following symptoms in the past 5 days (vaccinated) or 10 days (unvaccinated)? runny nose, sore throat, headache, muscle aches/pains, tiredness, nausea/vomiting diarrhea
*
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Not related to a known existing condition.
YES
NO
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8
Have you tested positive for Covid-19 in the past 5 days (vaccinated) or 10 days (unvaccinated)?
*
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On a PCR test or rapid test.
YES
NO
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9
Do you live with someone who is isolating due to a positive test, waiting for test results or has Covid-19 symptoms?
*
This field is required.
Answer NO if you have had a booster, are a double vaccinated youth 11-17 or have tested positive in the past 90 days.
YES
NO
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10
Have you been told that you should be isolating?
*
This field is required.
Due to contact tracing or close contact.
YES
NO
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11
Have you travelled outside of Canada in the past 14 days?
*
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YES
NO
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