COVID-19 Pre-Assessment Questionnaire

 

Do you have a fever, new onset of cough, worsening chronic cough, short ness of breath or difficulty breathing?
Did you have close contact with anyone with acute respiratory illness or travelled outside of Canada in the past 14 days?
Do you have a confirmed case of the coronavirus?
Did you have close contact with a person who has a confirmed case of the coronavirus?
Do you have two or more of the following symptoms; sore throat, runny nose/sneezing, nasal congestion, hoarse voice, difficulty swallowing, decrease or loss of sense of smells, chills, headaches, unexplained fatigue/malaise, diarrhea, abdominal pain or nausea/vomiting?
For 65+: Are you experiencing any of the following; delirium, falls, acute functional decline, or worsening of chronic conditions?

As the COVID-19 pandemic increases day by day, the safety of our staff and facility is our top priority. As an additional security measure, the clinic has introduced a mandatory pre-assessment questionnaire for ALL patients. Upon completion of the questionnaire, the patient is required to sign below indicating acceptance of the following: I, the patient, agree that I have answered the above questions to the best of my knowledge and have disclosed nothing but the truth. Any further questions or concerns can be directed to the receptionist on-duty.

Your Signature

© 2020 by Cadence Health Centre. 

200 Spadina Avenue, Toronto, Ontario

Tel: 416-203-8600

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