COVID-19 Pre-Screening Form

Your Name:

Your Appointment Date:

Have you tested positive for COVID-19? YesNo

Are you awaiting results for a COVID-19 test? YesNo

Do you have a fever over 37.8°C (100.4°F) or chills? YesNo

Do you have a new or worsening cough? YesNo

Do you have a sore throat?YesNo

Do you have a runny nose or nasal congestion that you wouldn't normally have because of seasonal allergies or another pre-existing condition?YesNo

Do you have other cold- or flu-like symptoms? YesNo

Are you having new or worsening shortness of breath or other difficulties breathing? YesNo

Have you experienced a recent loss of taste or smell? YesNo

Are you feeling tired or fatigued without explanation? YesNo

Do you have a new or worsening headache? YesNo

Do you have nausea, vomiting, diarrhea or abdominal pain? YesNo

Even if you do not currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?YesNo

Have you returned from travel outside of Canada in the past 14 days?YesNo

Signature:

Press the button below to submit the completed screening form.