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.