Leave this field blank Use this form to screen patients befor their appointment and when they arrive for their appointment. (optional) Patient Name: Patient Age: Who answered: Patient Other Specify Contact Method: Phone Email Other Email address Specify Screening Questions (optional) Have you had close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days? Yes No Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19? Yes No Do you have any of the following? (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) Yes No Are you 70 years of age or older, experiencing any of the following symptoms: delirium, uneexplained or increased nummber of falls, acute functional decline, or worsening of chronic conditions? Yes No Send