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Covid-19 Screening Form - Mandatory for Tao Health
Please fill Covid-19 Screening Form 24 hours before appointment.
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* Indicates required question
Email
*
Your email
What day is it today?
*
MM
/
DD
/
YYYY
Patient Full Name (First and Last)
Your answer
Patient Address
Your answer
Phone Number
Your answer
Do you have any of the following new or worsening symptoms or signs*? Symptoms should not be chronic or related to other known causes or conditions.
*
fever (37.8°C or higher) and/or chills
cough or barking cough
shortness of breath
decrease or loss of smell or taste
sore throat
difficulty swallowing
runny or stuffy/congested nose
pink eye (conjunctivitis)
headache that is unusual or long lasting
nausea/vomiting, diarrhea, abdominal pain
muscle aches that are unusual or long lasting
extreme tiredness that is unusual
* Not related to COVID-19 vaccine in the last 48 hours or other known causes or conditions you already have
No to all
Required
Have you travelled outside of Canada in the last 14 days?
*
Yes
No
In the last 14 days, has a public health unit identified you as a “close contact” of someone who currently has COVID-19?
*
Yes
No
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
*
Yes
No
In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?
*
Yes
No
Did you have close contact with anyone (including household members) with COVID-19 symptoms in the last 14 days who has not been tested or is awaiting COVID-19 test results?
*
Yes
No
A copy of your responses will be emailed to the address you provided.
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