Patient Screening Form

Patient Name *

Patient Age *

1. Have 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 *

Yes

No

Any new, unusual symptoms, e.g., feeling unwell, or sudden onset of runny nose, pink eye (conjunctivitis) *

Yes

No

3. Have 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 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 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

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COVID-19 Patient Screening