COVID SCREENING QUESTIONNAIRE
DATE of VISIT:__________________________________
DO YOU HAVE ONE OR MORE OF THE COVID SYMPTOMS LISTED BELOW:
- Fever and/or chills
- Cough or shortness of breath
- Sore throat or difficulty swallowing
- Decrease or loss of taste or sense of smell
- Runny/congested nose or headache
- Muscle Aches or Extreme Tiredness
- Pink Eye or Stomach Pain (Adults)
- Falling down often (Older Adults)
COVID RISK ASSESSMENT
- Has a doctor, health provider or health unit told you that you should be self-isolating?
- Have you been identified as a close contact of someone who currently has Covid-19 in the last 14 days?
- Have you received a COVID Alert exposure notification on your cell phone in the last 14 days (and have not been tested or are awaiting your result)?
- Have you or anyone you live with travelled outside of Canada in the last 14 days?
- Is anyone you live with experiencing any new COVID symptoms and/or waiting for COVID-19 test results after experiencing symptoms?
DID YOU ANSWER YES TO ANY OF THE ABOVE QUESTIONS?
If the answer is YES to any of these questions, PLEASE DO NOT ENTER this location AND contact your health provider, local health unit or Telehealth (1-866-797-0000) for assessment and to see if you need a COVID-19 test.
Thank you for your cooperation in keeping our staff, clients and visitors safe!
Staff and Veterinarians, Ilderton Pet Hospital