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COVID-19 : Patient Screening
Before the appointment
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First Name
Last Name
Date
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Day
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Month
Year
Date
COVID-19 : PATIENT / ATTENDANT SCREENING
In order to protect your health and safety as well as that of staff members and other patients during this exceptional period caused by COVID-19, the following persons must have completed this form before coming to the appointment:
Yes
No
1. Are you currently in self-isolation after testing positive for COVID-19?
2. Have you received a recommendation for a screening test, or are you awaiting a screening test result?
3. Have you been instructed to place yourself in preventive self-isolation, for example after returning from a trip or being in contact with a confirmed case of COVID-19?
4. If YES to questions 1, 2 or 3, are you considered as “recovered” by Public Health (i.e. after 14 days of self-isolation + 48 hours without fever or symptoms, or negative screening test after 14 days)?
Do you have the following conditions:
Yes
No
5. Fever, chills, cold sweats like during a flu (over 38 °C or 100.4 °F)?
6. Recent cough or chronic cough that has gotten worse?
7. Difficulty breathing, shortness of breath, difficulty speaking)?
8. Sudden loss of smell, taste or both?
9. Headache?
10. Intense fatigue?
11. Muscle pain unrelated to physical effort / exercise?
12. Sore throat?
13. Runny nose, nasal congestion?
14. Severe loss of appetite?
15. Nausea, vomiting?
16. Stomach pain, sore belly?
17. Diarrhea?
Do you have a known health condition that can explain the symptoms reported above? If YES, specify:
The person who completed the form must sign the form. I, the undersigned, solemnly declare that the answers contained in the form above are true.
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