Screening Questions for Patients 2022
For ALL IN-CLINIC Patients and Visitors, It is required to fill out this screening questionnaire for EACH VISIT to the clinic.
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Please Carefully read and answer ALL following questions:
1. Are you fully vaccinated against COVID-19?  Fully vaccinated is defined as an 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. *
2. Are you currently experiencing any of these issues: Severe difficulty breathing, Severe chest pain, Feeling confused or unsure of where you are, Losing consciousness? (If your answer is "Yes" call 911 or go directly to your nearest emergency department.) *
3. Are you currently experiencing any of these symptoms: Fever and/or chills, Cough or barking cough, Shortness of breath, Decrease or loss of taste or smell, Muscle aches/joint pain, Extreme tiredness, Sore throat, Runny or stuffy/congested nose, Headache, Nausea, vomiting and/or diarrhea, None of the above? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have. *
4. In the last 10 days, has someone you live with: Been sick with symptoms associated with COVID-19 and/or tested positive for COVID-19 (on a rapid antigen test or PCR test)? *
5. In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit? *
6. In the last 10 days, have you received a COVID Alert exposure notification on your cellphone? *
7. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19 (confirmed by a PCR or rapid antigen test)? (If public health has advised you that you do not need to self-isolate, selected “No.”
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8. In the last 14 days, have you travelled outside Canada? (If exempt from federal quarantine requirements as directed by the border agent at your point of entry (for example, you have two or more doses of a COVID-19 vaccine and have met the specific conditions, or an essential worker who crosses the Canada-US border regularly for work), select “No.”) *
If you answered "Yes" to any questions above from 2-8:
1. We ask that you please call the clinic and cancel your "in person" appointment and discuss other treatment options.
2. We ask that you complete the Ottawa Public Health online self assessment for the recommended course of action.
3. If needed call your primary care provider or Telehealth Ontario at 1-866-797-0000 or Public Health Ottawa at 613-580-6744 for further clinical assessment.
1. I have answered all the above questions honestly and truthfully.
2. By signing below, I consent and accept the inherent risks of in-clinic and in-person appointment in light of the COVID-19 Pandemic
and any potential exposure that occurs as a result.
Please write Patient/Visitor Full Name below which serves as electronic signature: *
Date: *
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