Covid-19 Pre-screening Form

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COVID-19 Pre-Screening

Please complete this form on the day of your appointment.

Background question

1. Have you received your final (or second) vaccination dose more than 14 days ago? *

Yes No

Screening Questions

2. Do you have any of the following symptoms? • Fever and/or chills • New onset of cough or worsening chronic cough • Shortness of breath • Decrease or loss of sense of taste or smell • If adult >18 years of age: unexplained fatigue, lethargy malaise muscle aches (myalgias) • If child <18 years of age: nausea/vomiting, diarrhea *

Yes No

3. Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating? *

Yes No

Questions 4 & 5 are to be completed only if you answered "no" to question 1.

4. Have you traveled outside of Canada in the past 14 days? *

Yes No

5. Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

Yes No

If response to ALL of the screening questions is NO: COVID Screen Negative (You can come to your appointment)
If response to ANY of the screening questions is YES: COVID Screen Positive (Please reschedule)

* Indicates required field

I have screened: *

Negative Positive

Name *

First

Last

Date *

If you feel unwell please stay home & self-isolate right away. Call Telehealth or your health care provider, to find out if you need a test.

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