Patient Screening Form

Date:
Do you have a fever or have felt hot or feverish anytime in the last two weeks?
YESNO
Do you have any of these symptoms: Dry cough? Difficulty breathing? Sore throat/painful swallowing? Runny nose/sneezing/post-nasal drip? Chills? Muscle aches? Headache? Fatigue?
YESNO
Have you experienced a recent loss of smell, taste or appetite?
YESNO
Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?
YESNO
Have you returned from travel outside of Canada in the last 14 days?
YESNO
Have you returned from travel within Canada from a location known affected with COVID-19?
YESNO
Is your workplace considered high risk?
YESNO
Have you had a COVID-19 vaccination to date?
YESNO

Patient Vulnerability

Are you over the age of 70?
YESNO
Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?
YESNO
* Please note, this form will be sent to us by email which is not as secure as some other forms of communication, but we will delete it as soon as we receive it.