COVID-19 SCREENING FORM Are you a current or new patient? New PatientCurrent Patient Patient Name Phone Email Date/Time Medical History 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). YesNo Question 2: Do you have any of the following symptoms? Fever and/or chillsNew onset of cough or worsening chronic coughShortness of breathDecrease or loss of sense of taste or smellIf adult >18 years of age: unexplained fatigue/lethargy/malaise/muscle aches (myalgias)If child <18 years of age: nausea/vomiting, diarrheanone Question 3: Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating? YesNo Question 4: Have you travelled outside of Canada in the past 14 days? YesNo Question 5: Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? YesNo Preferred Location Select LocationAltavistaBayshoreKanataStittsvilleWestgateDowntownOrleans Date
