Essential Health Centre COVID-19 Screening

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Full Name

Appointment Date

YYYY

Are you experiencing any of the following? (check off any that apply to you)

Chest Pain

Difficulty breathing

Having a hard time waking up

Feeling confused

Losing consciousness

Cough

None

Are you or anyone in your household or immediate "bubble" experiencing any cold, flu or COVID-19-like symptoms, even mild ones? This includes: Fever, chills, cough or worsening of chronic cough, shortness of breath, sore throat, runny nose, loss of sense of smell or taste, headache, fatigue, diarrhea, loss of appetite, nausea and vomiting, muscle aches, stuffy nose, confusion, abdominal pain, skin rashes or discoloration of fingers or toes.

Yes

Clear selection

Have you or anyone in your household traveled outside of British Columbia in the last 2 weeks?

Yes (Please contact your therapist, we may need to reschedule your appointment)

Have you had close contact with a person who has a confirmed case of COVID-19? (This means you would have been contacted by your health authority's public health team)

Yes

Clear selection

Submit

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