Patient screening COVID-19 Patient screening COVID-19Patient Name: *Patient age: Who answered: PatientOtherOther (specify): Contact Method:Phone: Email: Other: screening QuestionsHave you had close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days? YesNoDo you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19? YesNoIf you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? YesNoN/ADo you have any of the following symptomsFever YesNoNew onset of cough YesNoWorsening chronic cough YesNoShortness of breath YesNoDifficulty breathing YesNoSore throat YesNoDifficulty swallowing YesNoDecrease or loss of sense of taste or smell YesNoChills YesNoHeadaches YesNoUnexplained fatigue/malaise/muscle aches YesNoNausea/vomiting, Diarrhea, abdominal pain YesNoPink eye (conjunctivitis) YesNoRunny nose/nasal congestion without other known cause YesNo VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
