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COVID-19 Patient Screening Form
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* Indicates required question
Email
*
Your email
Patient Name
*
Your answer
Date
*
MM
/
DD
/
YYYY
1. Are you fully vaccinated? ie - Did you receive a second dose of Covid vaccine more than 14 days ago? (Note that children under 12 years of age will answer "no" to this question at this time)
Yes
No
Clear selection
2.
Does the patient have any of the following symptoms?
*
Fever and/or chills
New onset cough
Worsening chronic cough
Shortness of Breath
Decrease or loss of sense of taste or smell
If 18 years of age or older, unexplained fatigue/malaise/muscle pain (myalgia)
If under 18 years of age, Nausea/vomiting, diarrhea, abdominal pain
None of the above
Required
3. Have you tested positive for Covid-19 in the last 10 days or have you been told you should be isolating
*
Yes
No
Answer the following only if you answered "No" to question 1 ( you are not fully vaccinated ):
4. Have you travelled outside Canada in the last 14 days?
Yes
No
Clear selection
5. Have you had a close contact with a confirmed case of Covid-19 without wearing appropriate PPE?
Yes
No
Clear selection
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