Patient Screening Form
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Patient Name *
Patient Age *
Who is answering these questions? *
Contact Method *
Dispatch question for Long-Term Care or Retirement Home staff only: Do you have a concern for a potential COVID-19 infection for the person (e.g. is there an outbreak in the facility, is the patient awaiting COVID-19 test results, etc)? *
Have you returned from travel outside of Canada in the last 14 days? *
Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *
Do you have any of these symptoms: Fever, New onset of Cough, Worsening chronic cough, Shortness of breathing, Sore throat, Difficulty swallowing, Decrease of loss of sense of taste or smell, Chills, Headaches, Unexplained fatigue/malaise/muscle aches (myalgias), Nausea/vomiting, diarrhea, abdominal pain, Pink eye (conjunctivitis), Runny nose or nasal congestion without other known cause *
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, Worsening of chronic conditions *
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