COVID Screening Form

Use this form when your appointment is NOT today. If your appointment is today and you are outside the office, or will be here shortly, use this form.

If you would prefer to complete this screening another way, or are having technical difficulties, please phone our office during regular business hours (found on this page).

- Step 1 of 3

Please read each question carefully. This screening is only required for the patient, not anyone who may be accompanying them to their appointment.

Are you being screened for an appointment that is NOT today?

• Yes
• No

STOP HERE!

Only use this form when: you're being screened for an appointment that is not today. In the case of screening for an appointment happening today, stop and use this form.

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Next

Who is completing this screening?

• I am the patient
• I am responding on behalf of the patient

         e.g. the patient is my child

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Screening Questions

Screening Questions

For the patient, whom you are responding on behalf of.

Patient's name *

First

Last

Your name *

First

Last

i.e. the person responding on the patient's behalf

Your relationship to the patient *

Q&A for "I am the patient"

(this divider is hidden)

Do you have a confirmed case of COVID-19? *

• Yes
• No

Have you been in close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

• Yes
• No

Have you been in close contact with anyone with acute respiratory illness in the past 14 days? *

• Yes
• No

Have you travelled outside of Canada in the past 14 days? *

• Yes
• No

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 or loss of sense of taste/smell
• Chills
• Headaches
• Unexplained fatigue/malaise/muscle aches (myalgias)
• Nausea/vomiting, diarrhea, abdominal pain
• Pink eye (conjunctivitis)
• Runny nose/nasal congestion without other known cause

Do you have any of the symptoms listed: *

• Yes
• No

Q&A for "I am responding on behalf..."

(this divider is hidden)

Does the patient have a confirmed case of COVID-19? *

• Yes
• No

Has the patient been in close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

• Yes
• No

Has the patient been in close contact with anyone with acute respiratory illness in the past 14 days? *

• Yes
• No

Has the patient travelled outside of Canada in the past 14 days? *

• Yes
• No

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 or loss of sense of taste/smell
• Chills
• Headaches
• Unexplained fatigue/malaise/muscle aches (myalgias)
• Nausea/vomiting, diarrhea, abdominal pain
• Pink eye (conjunctivitis)
• Runny nose/nasal congestion without other known cause

Does the patient have any of the symptoms listed: *

• Yes
• No

Additional information *

Please describe why 1 or more questions was answered "Yes"

Comments

Optional information

Is there anything else we should know?

Affirmation

I affirm that the information I have provided above is complete and true, and I understand that providing false information may jeopardize the health of the staff, other patients and the general public. *

• Yes

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