COVID-19 Daily Screening Survey
Daily COVID-19 Screening

Please take this self-assessment prior to coming to the clinic each day to determine if you were exposed to COVID-19 or have symptoms. We have made some updates to reflect screening for fully immunized individuals. This screening must be completed regardless of whether or not you have been vaccinated.

Results of Screening Questions:
• If you answer NO to all questions from 1 through 7, you have passed and can enter the clinic. Please continue to wear your mask, maintain physical distancing, and use proper hand hygiene.
• If you answer YES to any questions from 1 through 7, you must not enter the clinic. You should go home to self-isolate immediately and contact your health care provider, the South West Public Health Unit @ (519) 631-9900, or Telehealth Ontario to find out if you need a COVID-19 test.

Thanks for helping keep all of us and our families safe.
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Email *
Your Name *
1. Are you currently experiencing one or more of the symptoms below that are new or worsening? (Check all that apply) Symptoms should not be chronic or related to other known causes or conditions. *
Required
2. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)? *
3. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *
4. In the last 10 days, have you been identified as a "close contact" of someone who currently has COIVD-19? **If public health has advised you that you do not need to self-isolate (e.g., you are fully immunized* or have tested positive for COVID-19 in the last 90 days and since been cleared), select “No.” ** *
5. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone? **If you are have already gone for a test and got a negative result, select "No." If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select "No." ** *
6. In the last 10 days, have you tested positive on a rapid antigen test or a homebased self-testing kit? **If you have since tested negative on a lab-based PCR test, select “No.”** *
7. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? **If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.”** *
If you answer YES to any questions from 1 through 7, you must not enter the clinic. You should go home to self-isolate immediately and contact your health care provider, the South West Public Health Unit @ (519) 631-9900, or Telehealth Ontario to find out if you need a COVID-19 test.
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