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COVID Screening Form

Welcome to our clinic!
Please take a few minutes to fill out this form as completely as you can.
If you have any questions we’ll be glad to help you.

Have you/they travelled outside of Canada in the past 14 days?
Have you/they tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
Do you/they have any of the following symptoms? Fever, cough, worsening chronic cough, shortness of breath, difficulty breathing, sore throat, difficulty swallowing, decrease or loss of taste and smell, chills, headaches, unexplained fatigue/malaise/muscle aches, nausea/vomiting, diarrhea, abdominal pain, pink eye (conjuntivitis), runny nose or nasal congestion without other known cause?
If you/they are 70 years of age or older, are you/they experiencing any of the following symptoms? Delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

Thanks for submitting!

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