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2020-11-18T18:49:00+00:00
Patient Name
*
Patient Age
*
1. Have you, or the person that is accompanying you, tested positive for COVID-19 in the past month or have been advised by your physician or local public health department to self-isolate?
Yes
No
2. Do you have or recently have had (within 10-14 days) any of the following symptoms:
Fever (above 37.8-38.0 degrees Celsius) or feeling hot, chills/feverish
*
Yes
No
Shortness of breath or other difficulties breathing
*
Yes
No
Cough or recent worsening of a chronic cough
*
Yes
No
Flu-like symptoms such as stomach upset, diarrhea, headache, fatigue or sore throat, without another known cause
*
Yes
No
Recent alteration or loss of taste or smell
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Yes
No
Any new, unusual symptoms, e.g., feeling unwell, or sudden onset of runny nose, pink eye (conjunctivitis)
*
Yes
No
3. Have you, or the person that is accompanying you, been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19 without wearing appropriate PPE? (Healthcare workers who have worn appropriate PPE may answer No)
*
Yes
No
4. Have you, or the person that is accompanying you, travelled in the past 14 days out of the country or to any COVID-19 hot spots?
*
Yes
No
5. In the past 14 days, have you, or the person that is accompanying you, been to any large gatherings where social distancing was not observed?
*
Yes
No
6. Do you have heart, lung or kidney disease, diabetes, or any auto-immune conditions?
*
Yes
No
7. Are you, or the person that is accompanying you, currently waiting for COVID-19 test results?
*
Yes
No
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