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Patient Screening Form
DesignCoast Creative
2022-03-23T13:15:41-07:00
PATIENT SCREENING FORM
1. Do you have a fever or have felt hot or feverish anytime in the last two weeks?
*
Yes
No
2. Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Sneezing? Post-nasal drip?
*
Yes
No
3. Have you experienced a recent loss of smell or taste?
*
Yes
No
4. Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?
*
Yes
No
5. Are you over the age of 80?
*
Yes
No
6. Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?
*
Yes
No
7. Have you returned from travel outside of Canada in the last 14 days?
*
Yes
No
8. Have you returned from travel within Canada from a location known affected with COVID-19? *
*
Yes
No
SUBMIT FORM
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