Patient Screening

Patient's full name: *

Have you had close contact with anyone with acute respiratory Illness? *

Yes

No

Scheduled date of the appointment: *

Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19? *

Yes

No

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

Are you waiting for results of a test for COVID-19? *

Yes

No

Have you travelled outside of Ontario OR been in contact with anyone who was outside of Ontario in the past 14 days? *

Yes

No

Accompanying person's full name (if applicable):

Has health authorities required you to self-isolate within the last 14 days? *

Yes

No