Appointment Health Screening
Thank you for completing this form honestly and protecting the health of our staff and other patients. If more than one person is attending, for example a child and parent, or multiple patient appointments you can use one form, but answer for all individuals.
1. Patient Name
First Name
Last Name
If more than one person is attending the appointment, please enter names and the reason.
Are you immunocompromised and/or live in a high-risk congregate care setting?
Yes
No
Do you currently have any of the following symptoms?
Fever or chills
Sore throat
Cough or barking cough
Runny or stuffy/congested nose
Shortness of breath
Decrease or loss of sense of taste or smell
Headache
Muscle aches/joint pain
Extreme tiredness
Nausea, vomiting, diarrhea
Abdominal pain
Pink eye
Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other government authority) that you should be currently quarantining, isolating, or staying at home?
Yes
No
In the last 10 days have you tested positive for Covid-19?
Yes
No
Submit
Should be Empty: