Pre-visit COVID-19 Screening

Patient Name *

First

Last

Did you receive your final (or second) vaccination dose more than 14 days ago? *

A fully immunized individual is defined as any individual 14 day after receiving ttheir second dose of a two-dose COVID19 vaccine series or their first dose of a one-dose series.

Do you have any of the following symptoms? *

Fever and/or Chills

New onset of cough *

New onset of cough or worsening chronic cough

Shortness of breath *

Shortness of breath

Decrease or loss of sense of taste or smell *

Decrease or loss of sense of taste or smell

Unexplained fatique/malaise/muscle aches (myalgias) *

For adults – Unexplained fatique/malaise/muscle aches (myalgias)

Nausea/vomiting, diarrhea, abdominal pain *

For children – Nausea/vomiting, diarrhea, abdominal pain

Have you tested positive for COVID-19 in the past 10 days or have you been told you should currently be isolating? *

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

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

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