COVID-19 SCREENING FORM Are you a current or new patient?* New Patient Current Patient Patient Name* First Last Phone*Email* Date MM slash DD slash YYYY Time Hours : Minutes AM PM AM/PM Question 1: Did you receive your final (or second) vaccination dose more than 14 days ago?** A fully immunized individual is defined as any individual >14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series (i.e .Johnson and Johnson). Yes No Question 2: Do you have any of the following symptoms?* Fever and/or chills New onset of cough or worsening chronic cough Shortness of breath Decrease or loss of sense of taste or smell If adult >18 years of age: unexplained fatigue/lethargy/malaise/muscle aches (myalgias) If child <18 years of age: nausea/vomiting, diarrhea none Question 3:Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?* Yes No Question 4: Have you travelled outside of Canada in the past 14 days?* Yes No Question 5: Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?* Yes No Preferred Location*Select locationAltavistaBayshoreKanataStittsvilleWestgateDowntownOrleansDate* MM slash DD slash YYYY
