Patient Screening Form

    Screening Questions

    Pre-Screen

    Have you travelled outside of Canada in the past 14 days?

    Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

    Do you have any of the following symptoms

  • Fever

  • New onset of cough

  • Worsening chronic cough

  • Shortness of breath

  • Difficulty breathing

  • Sore throat

  • Difficulty swallowing

  • Decrease or loss of sense of taste or smell

  • Chills

  • Headaches

  • Unexplained fatigue/malaise/muscle aches (myalgias)

  • Nausea/vomiting diarrhea.

  • abdominal pain

  • Pink eye (conjunctivitis)

  • Runny nose/nasal congestion withoutother known cause

    • If you are 70 years of age or older, are you experiencing any of the following symptoms: delinium. unexplained or increased number of falls, acute functional decline. or worsening of chronic conditions?