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 ‘NO’ to ALL of the following questions:

 

  1. Have you had close contact with anyone with acute respiratory illness or have you traveled outside of Ontario in the past 14 days?
  2. Do you have a confirmed case of Covid-19 or have you had close contact with a confirmed case of Covid-19?
  3. Do you have any of the following symptoms:
    • Fever
    • New onset of cough
    • Worsening chronic cough
    • Shortness of breath
    • Difficulty breathing
    • Sore throat
    • Difficulty swallowing
    • Decrease or loss of sense of taste or smell
    • Chills
    • Headaches
    • Unexplained fatigue/malaise/muscle aches (myalgias)
    • Nausea/vomiting, diarrhea, abdominal pain
    • Pink eye (conjunctivitis)
    • Runny nose/nasal congestion without other known cause
  1.  If you are 70 years of age or older, are you experiencing any of the following symptoms:
    • Delirium / confusion
    • Unexplained or increased number of falls
    • Acute functional decline
    • Worsening of chronic conditions
    • Fever/feverish, new or existing cough and difficulty breathing

 

If you answered ‘YES’ to any of these questions, we are unable to treat you for a minimum of 14 days.

If you answered "YES" to question 3 but feel that one or more listed symptoms are 'normal' for you (ie. headaches, nausea) and are not 'NEW' or 'UNEXPLAINED' then please call the office for further screening.

If 'YES' to all the questions and your symptoms are NEW AND UNEXPLAINED, 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.

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

 

*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: