Patient Screening Form Patient Name:AgeEmail AddressScreening Questions1. Do you have a fever or have felt hot or feverish anytime in the last two weeks?YesNo2. Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing?Sore throat? Runny nose? Sneezing? Post-nasal drip?YesNo3. Have you experienced a recent loss of smell or taste?YesNo4. Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolatingbecause of a determined risk for COVID-19?YesNo5. Have you returned from travel outside of Canada or British Columbia in the last 14 days?YesNo6. Is your workplace considered high risk?YesNoPatient Vulnerability7.Are you over the age of 70?YesNo8. Do you have any of the following: Heart disease, lung disease, kidney disease, diabetes or anyauto-immune disorderYesNo9.Is there any additional information you’d like us to have?Please note that no data transmission over the internet can be guaranteed to be 100% secure. As a result, we cannot guarantee the security of any information you transmit to us over the internet, and you do so at your own risk If you would prefer to contact us by telephone to complete this screening questionnaire, please call: 604-522-5242 Send Message
