• COVID-19 Screening Form for Patients

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 1. Have you had close contact with anyone with acute respirator illness or with anyone who has travelled outside of Ontario in the past 14 days?*
  • 2. Have you returned from travel outside of Ontario in the past 14 days?*
  • 3. Have you tested positive for COVID-19?*
  • 4. Have you had close contact with a confirmed case of COVID-19?*
  • 5. Do you have any of the following symptoms?*
  • 6. If the person is 70 years of age or older, are they experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?*

  • If response to ALL of the screening questions is NO: COVID SCREEN NEGATIVE * (Initial) 

  • If response to ANY of the screening questions is YES: COVID SCREEN POSITIVE (Initial)

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