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)


     

    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.