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COVID-19 Screening
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2020-07-21T10:41:17-04:00
COVID-19 Screening
First and Last Name
*
Date
*
1. Have you travelled outside of Canada in the past 14 days?
*
Yes
No
2. Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
*
Yes
No
3. Do you have any of the following symptoms?
Decrease/loss of sense of taste or smell
Worsening chronic cough
Difficulty breathing
Difficulty swallowing
Runny nose/nasal congestion with no known cause
Unexplained fatigue/malaise/muscle aches
Nausea/vomiting, diarrhea, abdominal pain
New onset of cough
Shortness of breath
Sore throat
Headache
Pink eye
Chills
Fever
4. If you are 70 years of age or older, do you have any of the following symptoms?
Delirium
Unexplained or increased number of falls
Acute functional decline
Worsening of chronic conditions
• If you have answered NO to all questions and do not exhibit any of the listed symptoms, then you may proceed with your appointment.
• If you have answered YES to any questions or any symptom then you may be asked to reschedule your appointment and further questioning may be required.
Consent
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