Name:  _________________________             Date:  _____________

Screening Questions                                                 

  1. Do you have any of the following new or worsening symptoms or signs? 
New or worsening Cough Yes No
Shortness of Breath Yes No
Sore Throat Yes No
Runny Nose, sneezing or nasal Congestion Yes No

(in absence of underlying reasons for symptoms such as seasonal allergies and post nasal drip)
Hoarse voice Yes No
Difficulty Swallowing Yes No
New Smell or taste disorder(s) Yes No
Nausea / Vomiting, diarrhea, abdominal pain Yes No
Unexpected fatigue/malaise Yes No
Chills Yes No
Headache Yes No

2. Have you travelled outside of Canada or had close contact with anyone that has travelled outside of Canada in the past 14 days? 

   Yes                                  No

3. Do you have a fever? 

  Yes                                    No

4. Have you had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19? 

  Yes – go to question 5       No – screening complete

5. Did you wear the required and/or recommended PPE according to the type of duties you were performing (e.g., goggles, gloves, mask and gown or N95 with aerosol generating medical procedures (AGMPs)) when you had close contact with a suspected or confirmed case of COVID-19? 

  Yes                                    No

Analysis of Results to Screening Questions:

ABLE TO ENTER THE CLINICNOT PERMITTED TO ENTER THE CLINIC
AnswersNO to ALL Questions’ 1-4 Answers Yes to Question 4 and 5, and does not have a feverAnswers Yes to ANY Questions’ 1-3 Answers Yes to Question 4, and No to Question 5

Administered by:  ______________________________    Date:  ______________

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