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COVID-19 Patient Screening
Please answer the following questions to ensure you are COVID-19 symptom free.
Patient Name
*
Date
*
It is important to closely monitor your health and the health of those you care for to help prevent the spread of COVID-19 and other illnesses like the flu.
1. Do You Feel Sick?
*
Yes
No
2. In the past 48 hours, have you had, or are you currently experiencing;
Cough (New or Worsening)
*
Yes
No
OR two or more of the following symptoms (new or worsening);
Fever (i.e. chills/sweats)
*
Yes
No
Sore Throat
*
Yes
No
Runny nose/nasal congestion
*
Yes
No
Headache
*
Yes
No
If yes, go home or stay home as noted above. Follow Public Health instructions for testing and isolation.
3. Have you recently visited a COVID-19 exposure site?
*
Yes
No
4. Have you travelled in the past 14 days outside of the province and/or country AND been advised to self-isolate?
*
Yes
No
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