My COVID Screen

Question 2:

• I understand and agree to following arrival requirements:
  • Only the patient and one parent/attendant will present themselves for the appointment
  • Masks will be donned prior to entry to the clinic
  • Masks will be worn through the entirety of our time in the building.

Question 3:

• My mask (patient and attendant) is compliant with the following:
  • Acceptable masks:
    • Must securely cover the nose, mouth and chin without gaping
    • If wearing cloth masks: Minimum 3 layers with a minimum of 2 layers of tightly woven fabric such as cotton or linen
    • Medical procedure or surgical mask, KN95, N95 or higher
  • Unacceptable masks:
    • Masks with vents or exhalation valves
    • Bandanas, neck gaiters/tubes
    • “Mouth shields”
    • Any material, design or usage which does not adequately impede and trap exhaled micro and macroparticles

Question 4:

• Has the patient OR parent/attendant experienced ANY of the following in the last 14 days?
  • Fever
  • Cough
  • shortness of breath or difficulty breathing
  • Runny nose
  • Sore throat
  • Chills
  • Rigors (paroxysmal shaking/shivering)

Question 5:

• Has the patient OR parent/attendant experienced ANY of the following in the last 14 days?
  • Painful swallowing
  • Nasal congestion
  • Feeling unwell
  • Fatigue
  • Significant exhaustion
  • Nausea or vomiting
  • Diarrhea

Question 6:

• Has the patient OR parent/attendant experienced ANY of the following in the last 14 days?
  • Loss of sense of smell
  • Loss of taste
  • Conjunctivitis (commonly known as pink eye)
  • Swelling of or on the eyeball itself (chemosis)
  • Changes in the skin or chillblains or rashes to fingers or toes (e.g. COVID toes)

Question 7:

• Has the patient OR parent/attendant experienced ANY of the following in the last 14 days
  • Altered mental status
  • Loss of appetite
  • New muscle, body or joint aches ie acute on chronic, not 100% attributable to preexisting known conditions
  • New headache ie acute on chronic, not 100% attributable to preexisting known conditions

Question 8:

• Have you had contact in the last 14 days with someone who was experiencing one or more symptoms we just asked about or developed these symptoms within 3 days after your contact?

Question 9:

• Have you tested positive for COVID-19 in the last 14 days (did the test results indicate that your sample showed the presence of the COVID-19 virus)?

Question 10:

• Are you awaiting COVID-19 test results (other than pre-departure travel testing)?

Question 11:

• In the past 14 days have you been in contact with anyone who is undergoing investigation for COVID-19?

Question 12:

• Have you been in contact with a confirmed or probable case of COVID-19 in the past 14 days?

Question 13:

• Are you currently under any self-isolation orders?

Question 14:

• Have you been instructed to self-isolate in the last 14 days?

Question 15:

• Are you currently under instruction to not be in school due quarantine orders or due to a COVID-19 exposure notification?

Question 16:

• Are you associated with a setting or facility that has an outbreak and have you been instructed to get tested or self-isolate?

Question 17:

• In the past 14 days have you returned to or entered Canada from outside the country (including the USA)? This is regardless of pre-travel or post-arrival testing results.

Question 18:

• Answer ‘NO’ if you are not a healthcare worker.

• OR

• If you are healthcare worker:
  • Have you had any contact with an at risk patient or patient with COVID-19 without wearing appropriate PPE?
  • OR
  • Have you had a laboratory exposure to biological material (i.e. primary clinical specimens, virus culture isolates) known to contain COVID-19 in the past 14 days?

Question 19:

• Press Yes to Proceed

Question 20:

• I Certify that my responses are true