SCREENING FOR YOUR APPOINTMENT

We are asking patients to please fill out our screening form prior to your appointment.  It’s our way of ensuring the safety of our patients, staff and the community at large. 

Thank-you for your cooperation. 


First and last name (required)


 
Date

Do you have any of the following symptoms?

Fever? YesNo

New or worsening cough?YesNo

Shortness of breath?YesNo

Sore throat?YesNo

Runny nose or sneezing?YesNo

Nasal congestion?YesNo

Hoarse voice?YesNo

Difficulty swallowing?YesNo

New smell or taste disorder(s)?YesNo

Nausea/vomiting, diarrhea, abdominal pain?YesNo

Unexplained fatigue/malaise?YesNo

Chills?YesNo

Headache?YesNo

 

Your Exposure

Have you been tested for Covid-19?YesNo

Date of testing

Results PositiveNegative

Have you travelled or had close contact with anyone that has travelled in the past 14 days?YesNo

Have you had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19?YesNo

Did you wear the required and/or recommended PPE according to the type of duties you performed (e.g., goggles, gloves, mask and gown or N95 with aerosol generating medical procedures (AGMPs)) when you had contact with a suspected or confirmed case of COVID-19?YesNo

Are all members of your home following The Canadian Public Health Associations guidelines with regards to Covid-19? This includes proper physical distancing. Canadian Public Health Guidelines can be found here: Preventing Coronavirus - Canadian Public Health YesNo

 

Your Appointment

Please read each statement and acknowledge your awareness by checking each box prior to submitting.