COVID-19 Patient Screening Form

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First Name & Last Name *

Date *

YYYY

Did you travel outside of Canada in the past 14 days? *

Yes

Required

Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

Yes

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 of 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 or nasal congestion without other known cause *

Yes

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• Worsening of chronic conditions *

Yes

Not Applicable

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