VISITOR* Covid-19 Screening Form
(*Visitors to the practice who are not patients, essential patient companions or staff members)
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Minutes
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PM
AM/PM Option
First Name
*
Last Name
*
Reason for visit
*
Do you have any of the following symptoms?
*
Yes
No
Fever
New onset of cough
Worsening of 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 or nasal congestion without other known cause
Pain or pressure in chest
Sluggishness or lack of appetite
Have you travelled outside of Canada in the past 14 days?
*
Yes
No
Have you tested positive for Covid-19 within the past three weeks?
*
Yes
No
Have you had close contact with a suspected or confirmed case of Covid-19 within the past month?
*
Yes
No
If you answered "Yes" to the question above, please provide details
*
Do any people who live with you have any of the symptoms outlined above?
*
Yes
No
How old are you?
*
Are you experiencing any of the following symptoms? (Please answer YES or NO for each)
*
YES
NO
Delirium
Unexplained or increased number of falls
Acute functional decline
Worsening of chronic conditions
Submit
Should be Empty: