Covid-19 Patient Screening Questionnaire

Name

Address

Phone number xxx-xxx-xxxx

Email Address

Appointment date YYYY-MM-DD

Have you travelled outside of Canada in the past 14 days? Have you travelled outside of Canada in the past 14 days? YES NO

Have you had close contact with a confirmed or probable case of COVID-19? Have you had close contact with a confirmed or probable case of COVID-19? YES NO

Do you have any of the following new or worsening symptoms or signs? (Symptoms should not be chronic or related to other known causes or conditions.): 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 without other known cause? Do you have any of the following new or worsening symptoms or signs? (Symptoms should not be chronic or related to other known causes or conditions.): 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 without other known cause? YES NO

Are you 70 years of age or older, and are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? Are you 70 years of age or older, and are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? YES NO

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