COVID-19 PATIENT SCREENING QUESTIONNAIRE

All patients must be screened prior to coming into the clinic as per Public Health Directives. When you call to  schedule your appointment, and upon arrival, you will be required to confirm that you have answered the following questions:

 

  1. Did you receive your final (second) vaccination more than 14 days ago?
  2. Do you have any of the following symptoms:
    • Fever and / or chills
    • New onset of cough or worsening of chronic cough
    • Shortness of breath
    • Decrease or loss of sense of taste or smell
    • If Adult >18 years of age: UNEXPLAINED fatigue / lethargy / malaise / muscle aches (myalgias)
    • If child <18 years of age: nausea / vomiting / diarrhea
  3. Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?

 

If you answered 'YES' to question 1. and 'NO' to questions 2. and 3. please fill in your name and email below and click the confirmation button. Please review our policies and procedures before coming to the clinic.

 

If you answered 'NO" to question 1. (you are not fully immunized), then please answer questions 4 and 5 below:

   4. Did you travel outside of Canada in the last 14 days?

   5. Have you had close contact with a confirmed case of COVID-19 without  wearing         appropriate PPE?

 

If you answered 'NO' to questions 4 and 5, Please fill in your name and email below and click the confirmation button. Please review our policies and procedures before coming to the clinic.

 

If you are not fully immunized (second dose >14 days ago) and answered 'YES' to questions 4 or 5, you should complete the Ontario Government's Self Assessment and contact an appropriate authority such as your family physician, local medical officer of health or Telehealth Ontario.

 

 

*Please note that the Ministry of Health allows for the questions to be adapted based on need/setting. As some of these symptoms (most notably headaches) are frequently treated in a clinical setting, we would recommend that you assess whether your symptom is new/unusual. Front line workers who have potentially been exposed can disclose this with appropriate notations made in their file.

Thank you for your support and understanding.

 

If you are a client / patient of Dr. Tousignant, Dr. Stewart, Nicole Gleeson or Cynthia Love please fill out your confirmation here:

If you are a client / patient of Dr. Higgins or Shaun Harris, please fill out your confirmation here: