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
