Patient Wellness Screening

Home/Patient Wellness Screening

Name *

First

Last

Email *

Have you had close contact with anyone with acute respiratory illness or traveled outside of Canada in the past 14 days? *

Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19? *

Fever over 38°C (100.4°F) or chills? *

New or worsening cough? *

Sore throat? *

Runny nose or nasal congestion without other known causes? *

Worsening Chronic cough? *

Shortness of breath or other difficulties breathing? *

Decrease or loss of taste or smell? *

Unexplained fatigue/malaise aches (myalgias)? *

New or worsening headache? *

Nausea, vomiting, diarrhea, abdominal pain, or Pink eye (conjunctivitis)? *

Difficulty swallowing? *