Patient Screening Form

    Screening QuestionsPre-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 without other known cause
    YesNo

    If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

    YesNo