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COVID Screening Form

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Covid-19 Patient Screening Form

You are required to wear a mask in the office at all times as per RCDSO
PRE- APPOINTMENT
IN-OFFICE (Please Leave Blank for Clinic Staff to Complete)
MM slash DD slash YYYY
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Do you have fever or have you/they felt hot or feverish recently (14-21 days)?
Have Fever (PRE- APPOINTMENT)*
Have Fever (IN-OFFICE)
Are you having shortness of breath or other difficulties breathing?
Shortness of Breath (PRE- APPOINTMENT)*
Shortness of Breath (IN-OFFICE)
Do you have a cough?
Have a Cough (PRE- APPOINTMENT)*
Have a Cough (IN-OFFICE)
Any other flu-like symptoms, such as gastrointestinal upset, headache, fatigue, sore throat, hoarse voice, difficulty swallowing, chills, unexplained fatigue, diarrhea, nausea, vomiting, pink eye, runny nose/ sneezing/nasal congestion without any known cause.
Have Flue (PRE- APPOINTMENT)*
Have Flue (IN-OFFICE)
Have you experienced recent loss of taste or smell?
Loss Of Smell (PRE- APPOINTMENT)*
Loss Of Smell (IN-OFFICE)
Are you in contact with any confirmed COVID-19 positive patients WITHOUT wearing proper PPE?
Contact with any confirmed COVID-19 (PRE- APPOINTMENT)*
Contact with any confirmed COVID-19 (IN-OFFICE)
Are you age over 70? Experiencing: delirium, unexplained or increased number of falls, acute functional decline or worsening of chronic symptoms?
Over 70 (PRE- APPOINTMENT)*
Over 70 (IN-OFFICE)
Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
Heart Diesease (PRE- APPOINTMENT)*
Heart Diesease (IN-OFFICE)
Have you traveled in the past 14 days to any region affected by COVID-19? (as relevant to your location). Have you come into contact with someone who has traveled in the past 14 days?
Have you Traveled (PRE- APPOINTMENT)*
Have you Traveled (IN-OFFICE)
MM slash DD slash YYYY
MM slash DD slash YYYY

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