Printable COVID Form

COVID SCREENING QUESTIONNAIRE

 

DATE of VISIT:__________________________________

 

CLIENT NAME:__________________________________

 

PATIENT NAME:_________________________________

 

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
  • Nausea/Vomiting/Diarrhea
  • Muscle Aches or Extreme Tiredness
  • Pink Eye or Stomach Pain (Adults)
  • Falling down often (Older Adults)

____YES

____NO

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?

___YES

___NO

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