COVID-19 Screening Tool

 

1. Do any of the following apply to you?

• I am fully vaccinated against COVID-19 (it has been 14 days or more since your final dose of either a two-sdow or a one-dose vaccine series)

• I have tested positive of COVID-19 in the last 90 days (and since been cleared by the local public health unit)

 

⬜Yes ⬜No     If Yes, skip questions 7 - 10

 

1. Are you currently experiencing one or more of the symptoms below that are new or worsening? This should not include symptoms related to a chronic condition:

• Fever and/or chills

• Cough or barking cough

• Shortness of breath

• Decrease or loss of smell or taste

• Unusual tiredness, lack of energy - not associated with having had a COVID-19 vaccine in the last 48 hours

 

1. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine? 

⬜Yes ⬜No

 

1. Has a doctor, health care provider, or public health unit told you that you should currently be isolating?

⬜Yes ⬜No 

 

1. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?

If public health has advised you that you do not need to self-isolate, select ‘No’.

⬜Yes ⬜No 

 

1. In the last 10 days, have you tested positive on a rapid antigen test?

⬜Yes ⬜No

 

1. In the last 14 days, has someone in your household travelled outside of Canada AND been advised to quarantine?

⬜Yes ⬜No

 

1. In the last 14 days, has someone in your household been identified as a “close contact” of someone who currently has COVID-19 AND  been advised to self-isolate?

⬜Yes ⬜No

 

1. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

⬜Yes ⬜No

 

Results of Screening Questions:

• If you have answered YES to any questions 2 through 10, please contact the clinic prior to attending your appointment.