COVID-19 Screening Form
Please complete the following questions before your appointment or work day.
First Name
Last Name
Phone Number
Do you have any of the following?
Fever/Chills *
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Cough
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Clear selection
Difficulty Breathing/Shortness of Breath
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Clear selection
Sore throat/difficulty swallowing
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Clear selection
Runny Nose (Unrelated to seasonal allergies)
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Clear selection
Loss of taste or smell
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Not feeling well headache, unexplained tiredness and muscle aches
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Clear selection
Nausea, vomiting, diarrhea, abdominal pain
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Clear selection
In the past 14 days Have you been in close contact with a person who: was sick with a respiratory illness (had a new or worsening cough, fever or difficulty breathing)?· has returned from travel outside of Canada in the last 14 days?· was a confirmed or probable case of COVID-19?
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Clear selection
In the last 14 days, have you travelled outside of Canada?
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If you answered YES to any of these questions, please return home and self-isolate. Visit OttawaPublicHealth.ca/COVIDCentre for more information about getting tested. If you are feeling unwell, contact your health care provider or call Telehealth Ontario at 1-866-797-0000 to speak to a registered nurse. Adapted from Ottawa Public Health.
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