Please complete our COVID-19 pre-screening form

Patient First & Last Name



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Did the person have close contact with anyone with acute respiratory illness?

Yes

No


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Did the person travel outside of Ontario in the past 14 days?

Yes

No


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Does the person have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?

Yes

No


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Is experiencing any of the following symptoms:
. Fever
. New onset of cough
. Worsening chronic cough
. Shortness of breath
. Difficulty breathing
. Sore throat
. Difficulty swallowing
. Chills
. Headaches

Yes

No


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Is experiencing any of the following:
. Decrease or loss of sense of taste or smell
. Unexplained fatigue/malaise/muscle aches (myalgias)
. Nausea/vomiting, diarrhea, abdominal pain
. Pink eye (conjunctivitis)
. Runny nose/nasal congestion

Yes

No


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If the person is 70 years of age or older, are they experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

Yes

No


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