COVID-19 Questionnaire & Informed Consent Clinic 360 ACUTE INFECTION (COVID-19) ILLNESS SCREENING TOOL FOR STAFF AND PATIENTS SYMPTOMSDo you have any fever or chills?* No Yes Do you have a new or worsening cough?* No Yes Do you have a new or worsening shortness of breath?* No Yes Do you have any of the following gastrointestinal symptoms?Nausea?* No Yes Vomiting?* No Yes Diarrhea?* No Yes Abdominal Pain?* No Yes Have you failed to use social distancing in the last 2 weeks?* No Yes Have you received the 1st dose of the COVID-19 vaccine?* No Yes Have you received the both doses of the COVID-19 vaccine?* No Yes HISTORY OF TRAVELHave you traveled outside Canada within the last 2 weeks?* No Yes If yes, please specify Have you met anyone suspected of having COVID-19 in the last 2 weeks?* No Yes Have you met anyone diagnosed with having COVID-19 in the last 2 weeks?* No Yes Have you contact with a sick person who has traveled outside Canada in the last 2 weeks?* No Yes If yes, please specify where the person has traveled to and when INFORMATIONName*Patient/Staff Staff Staff OHIP #Patient Only EmailPatient Only PhonePatient OnlyConsent* By initiating this form, I confirm that my answers are true and have been answered to the best of my ability. Initiate*Patient/Staff Date*Patient/Staff Initiate YYYY slash MM slash DD EmailThis field is for validation purposes and should be left unchanged. Let’s Talk Book Your Consultation Today at 416-360-7-360! Book Appointment
