COVID-19 SCREENING FORM

Full Name:*

Phone number:*

Have you been diagnosed with COVID-19 at anytime?*

If yes please indicate w hen:

Does the patient have risk for COVID-19 exposure? In the last 14 days has the patient:

Returned from travel outside of Canada?*

If yes, When? Date:

Been in contact with anyone with confirmed diagnosed COVID-19?*

If yes, When? Date:

Lived or worked in a setting that is part of a COVID-19 outbreak?*

If yes, When? Date:

Been advised to self-Isolate or quarantine at home by public health?*

If yes, When? Date:

Fever*

Cough*

Shortness of Breath*

Diarrhea*

Nausea and/or vomiting*

Headache*

Runny nose/ nasal congestion*

Sore throat or painful swallowing*

Loss of sense of smell*

Chills*

Muscle aches*

Fatigue*