Patient Screening

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Patient Screening - COVID-19

If you have submitted your form and experience any changes to your health or have new symptoms prior to your appointment, please contact us at 416-233-0066

Patient Name: *

First Name Last Name

Patient age: *

Who is completing this questionnaire?: *

Patient

Please answer the following questions:

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

Yes No

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

Yes No

Do you have any of the following symptoms: *

Yes

No

Fever

New onset of cough

Worsening chronic cough

Shortness of breath

Difficulty breathing

Sore throat

Difficulty swallowing

Decrease or loss of sense of taste or smell

Chills

Headaches

Unexplained fatigue/malaise/muscle aches (myalgias)

Nausea/vomiting, diarrhea, abdominal pain

Pink eye (conjunctivitis)

Runny nose/nasal congestion without other known cause

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

Yes No

Date:

Date

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