COVID-19 Patient Pre-Screening Form COVID-19 Patient Pre-Screening Form The following form needs to be completed within 24 hours prior to your appointment. Personal Information First Name * Last Name * Email * Phone Number * Have you tested positive for COVID-19 or are you awaiting test results for a COVID-19 test? * Yes No Are you, or have you in the last 14 days, in contact with any confirmed COVID-19 positive patients? * Yes No Have you travelled outside of Ontario in the past 14 days? * Yes No Do you have any of the following: Fever * Yes No New onset of cough * Yes No Worsening chronic cough * Yes No Shortness of breath * Yes No Difficulty breathing * Yes No Sore throat * Yes No Difficulty swallowing * Yes No Decrease or loss of sense of taste or smell * Yes No Chills * Yes No Headaches * Yes No Unexplained fatigue/malaise/muscle aches (myalgias) * Yes No Nausea/vomiting, diarreah, abdominal pain * Yes No Pink eye (conjunctivitis) * Yes No Runny nose/nasal congestion without other known cause * Yes No Even if you do not currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days? * Yes No Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder? * Yes No Are you experiencing any of the following symptoms: delirium, unexplained or increase number of falls, acute functional decline, or worsening of chronic conditions? * Yes No Comments: Date * Patient/Guardian Signature * signature keyboard Clear Submit
