COVID-19 Screening Form
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
1. Did you receive your final (or second) vaccination dose more than 14 days ago?
*
Yes
No
Not Sure
1a. Please answer only if you selected No or No Sure for Question 1: Did you travel outside of Canada in past 14 days?
Yes
No
Not Sure
1b. Please answer only if you selected No or No Sure for Question 1: Have you had close contact with a confirmed case of COVID-19?
Yes
No
Not Sure
4. Do you have any of the following symptoms?:
*
Fever and/or chills
New and persistent cough
Shortness of breath or any difficulty breathing
Decreased sense of taste or smell
If adult greater than 18 years of age: unexplained fatigue/lethargy/malaise/muscle aches (myalgias)
If child less than 18 years of age: nausea/vomiting, diarrhea
No, I don't have any of those symptoms
Not Sure
5. Have you tested positive for COVID-19 in the past 10 days or have been told you should be isolating?
*
Yes
No
Not Sure
6. Dispatch question only for Long-Term Care or Retirement Home staff: Is the patient concerned about a potential COVID-19 infection?
Yes
No
Not Sure
Not Applicable
I understand the potential health risks asociated with unintentional exposure to the COVID-19 virus. By signing below, I agree to release this facility and it's staff from all liability concerning any possible exposure and health risks associate with COVID-19 I may encounter due to my procedure.
Name
*
First Name
Last Name
Signature
*
Submit
Should be Empty: