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COVID-19 PRE-SCREENING QUESTIONNAIRE

PRE-SCREENING QUESTIONNAIRE

Do you have any of the following symptoms:

  1. A. Fever, new onset of cough, worsening chronic cough, shortness of breath or difficulty breathing
  2. B. Any close contact with a patient who has had an acute case of respiratory illness or have travelled outside of Ontario in the last 21 days.
  3. C. Are you or anyone in your household/close contacts waiting for COVID results, or are COVID positive or in self isolation?
  4. Have you been to a facility such as hospital or LTC within the last 14 days with a recent COVID outbreak

OR any ONE of the below symptoms:

  • sore throat
  • Hoarse voice
  • difficulty swallowing
  • decrease or loss of smell or taste
  • chills
  • headaches
  • unexplained fatigue
  • diarrhea, abdominal pain,
  • nausea or vomiting
  • pink eye
  • runny nose without other known cause, nasal congestion without known cause

IF Yes: we will need to reschedule your appointment

IF No: present for your visit. One more screening and temperature check will be had at arrival.