Patient Screening Form

Screening Questions	Pre-Screen
Have you travelled outside of Canada in the past 14 days?	YesNo
Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?	YesNo
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	YesNo
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?	YesNo