COVID-19 Screening Questionnaire

Do you have any of the following symptoms: fever, new onset of cough, worsening chronic cough, shortness of breath, difficulty breathing, sore throat, difficulty swallowing, loss of taste or smell, chills, headaches, unexplained fatigue, pink eye, runny nose/ congestion without other known cause?

YesNo

Have you traveled outside Ontario in the last 14 days?

YesNo

Has there been any significant changes to your health since your last visit?

YesNo

If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

YesNo

In order to protect out patients health, we reserve the right to reschedule your appointment.

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