Pre-visit COVID-19 Screening

Patient Name *

First

Last

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

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

Do you have any of the following symptoms? *

Fever

New onset of cough *

New onset of cough

Worsening chronic cough *

Worsening chronic cough

Shortness of breath *

Shortness of breath

Difficulty breathing *

Difficulty breathing

Sore throat *

Sore throat

Difficulty swallowing *

Difficulty swallowing

Decrease or loss of sense of taste or smell *

Decrease or loss of sense of taste or smell

Chills *

Chills

Headaches *

Headaches

Unexplained fatique/malaise/muscle aches (myalgias) *

Unexplained fatique/malaise/muscle aches (myalgias)

Nausea/vomiting, diarrhea, abdominal pain *

Nausea/vomiting, diarrhea, abdominal pain

Pink eye (conjunctivitis) *

Pink eye (conjunctivitis)

Runny nose or nasal congestion without other known cause *

Runny nose or nasal congestion without other known cause

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

Do you work at a Long-term care or retirement home and have a concern for a potential COVID-19 infection (eg. is there an outbreak in the facility, it a patient in the facility awaiting COVID-19 test results, etc)? *

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Hours

Monday: 8am - 7pm

Tuesday: 8am - 7pm

Wednesday: 8am - 7pm

Thursday: 7am - 5pm

Friday: 8am - 3pm

Saturday: By Appointment Only

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Pre-visit COVID-19 Screening