COVID-19 Patient Screening Form
Email address *
Patient Name *
Date *
1. Has the patient travelled outside Canada in the past 14 days? *
2. Does the patient have a confirmed case of COVID-19 or had close contact with a confirmed case of Covid-19 without wearing appropriate PPE? *
3. Does the patient have any of the following symptoms?
4. If you are 70 years of age or older, are you experiencing any of the following symptoms?
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy