COVID - 19 SCREENING FORM

Please fill out prior to your appointment

Additional visitors in appointment:

1. Do you currently have any of the following symptoms that are not chronic or related to
any other known causes or conditions?

CoughingShortness of breathDecreased appetite or smellNausea, vomitting, diarrheaFever and/ or chillsNone of the above

2. Have you travelled or been outside of Canada in the last 14 days and or have been told
to self isolate by Public Health?

YesNo

3. Do you live with or have been near someone with Covid -19 symptoms?

YesNo

4. Are you or someone you live been tested for Covid -19 and are awaiting results?

YesNo

If you have answered NO to all of these questions you may proceed with your appointment. If you have answered YES to any of these questions please contact clinic staff to reschedule or modify your appointment. Please contact your health provider or public health Canada if you have any symptoms.

*Please note that this form is kept on your file and is confidently kept in your file.