Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?
*
Yes
No
Patient COVID-19 Screening Form
If you are 70 years of age or older, indicate whether you have any of the symptoms below:
*
Delirium
Unexplained or increased number of falls
Acute functional decline
Worsening of chronic conditions
NO SYMPTOMS or NOT APPLICABLE
Accompanying person's full name (if applicable):
Are you waiting for results of a test for COVID-19?
*
Yes
No
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Screening
Have you travelled outside of Ontario OR been in contact with anyone who was outside of Ontario in the past 14 days?
*
Yes
No
Thank you for completing the patient COVID-19 screening form.
Have you had close contact with anyone with acute respiratory Illness?
*
Yes
No
Scheduled date of the appointment:
*
Indicate whether you have any of the symptoms below:
*
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 (myalgia)
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause
NO SYMPTOMS
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Has health authorities required you to self-isolate within the last 14 days?
*
Yes
No
Patient's full name:
*
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