Screening form COVID 19
For the health and safety of our community, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 symptoms.
Name
First Name
Last Name
Birth date
-
Month
-
Day
Year
Please add your birth date
PLEASE FILL BEFORE THE APPOINTMENT SECTION ONLY:
1- Have you tested positive for COVID-19 in the last 21 days or have you been told that you should be tested for COVID-19?
Yes
No
BEFORE THE APPOINTMENT
AFTER ARRIVAL AT THE CLINIC
DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS: (please only answer the pre-appointment column)
*
BEFORE THE APPOINTMENT
AFTER ARRIVAL AT THE CLINIC
2- Fever (over 38 °C or 100,4 °F) ?
Yes
No
Yes
No
3- New cough or worsening chronic cough ?
Yes
No
Yes
No
4- Difficulty breathing (e.g. shortness of breath or difficulty speaking) ?
Yes
No
Yes
No
5- Sudden loss of smell (with or without loss of taste) ?
Yes
No
Yes
No
6- Muscle pain, headache, intense fatigue or significant loss of appetite ?
Yes
No
Yes
No
7- Sore throat ?
Yes
No
Yes
No
8- Diarrhea ?
Yes
No
Yes
No
9- Do you have a known medical condition that could explain the above symptoms? If yes, specify below.
Yes
No
Yes
No
10- Have you been in close contact (at least 15 minutes within 2 metres) with a
confirmed or suspected case of COVID-19 ?
Yes
No
Yes
No
Other information to add
The person who completed the form must sign the form :
Patient
Attendant
I acknowledge that the information I've given is accurate and complete.
Signature
*
Clear
Date
-
Month
-
Day
Year
Date
Clinic Personnel Signature
Clear
Submit
Should be Empty: