Patient Pre-Screening Form
Please fill in this form at least 1 week - 48 hours prior to your appointment.
REMINDER: All patients must wait in their vehicle and call the office upon arrival. All patients are required to wear a mask and sanitize their hands upon entering the office.
Have you had close contact with anyone with acute respiratory illness or travelled outside of Canada in the past 14 days?
Do you have a confirmed case of Covid-19 or had close contact with a confirmed case of Covid-19?
Do you have any of the following symptoms:
New onset of cough
Worsening chronic cough
Shortness of breath
Decrease or loss of sense of taste or smell
Unexplained fatigue / malaise/ muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause
NONE OF THE ABOVE
If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?
If YES which of the following are you experiencing:
Unexplained or increased number of falls
Acute functional decline
Worsening of chronic conditions
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