COVID-19 Screening Tool

Screening questions that must be asked of patients and companions:

Do you have symptoms of COVID-19, such as:

  • • Fever (Initial)
  • • A new or changed chronic cough (Initial)
  • • A sore throat that is not related to a known or pre-existing condition (Initial)
  • • A runny nose that is not related to a known or pre-existing condition (Initial)
  • • Nasal congestion that is not related to a known or pre-existing condition (Initial)
  • • Shortness of breath that is not related to a known (Initial)

Have you travelled internationally within the last 14 days? YesNo

Have you had unprotected close contact with individuals who have a confirmed or presumptive diagnosis of COVID-19 (e.g. individuals exposed without appropriate PPE in use). YesNo

*Patients and/or companions exhibiting symptoms can not receive treatment at this time and should call Health
Link 811.

SIGNATURE OF PATIENT

What email address should this test copy be sent to?

I have read and understand the COVID-19 screening criteria

Printed Name: Date Signed: