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?