COVID-19 Patient Screening Form
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Screening Questions: Pre-Screen
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No
1. Do you have a fever or have felt hot or feverish anytime in the last two weeks?
2. Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Sneezing? Post-nasal drip?
3. Have you experienced a recent loss of smell or taste?
4. Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for
5. Have you returned from travel outside of Canada in the last 14 days?
6. Have you returned from travel within Canada from a location known affected with COVID-19?
7. Is your workplace high risk?
Patient Vulnerability: Pre-Screen
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Yes
No
8. Are you over the age of 70?
9. Do you have any of the following; Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?
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