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Home
About Us
Services
Patient Zone
Contact
Français
(514) 748-6586
COVID-19 SCREENING FORM FOR PATIENT / ACCOMPANYING VISITOR OF AGE 6-18+
This form is completed:
*
When making the appointment (Pre-op)
At the time of the appointment (Op)
Name of screened individual:
*
Please indicate if the name above corresponds to the patient or the accompanying visitor:
*
Patient
Accompanying visitor
Name of patient:
*
Age of screened individual:
*
18+ years old
6 to 17 years old
Have you tested positive for COVID-19, or have you received a recommendation to take a screening test?
*
Yes
No
If you answered yes to question 1, are you considered "recovered" by the regional public health department?
*
Yes
No
Have you been instructed to self-isolate (example: return from a trip abroad for less than 14 days, contact with a confirmed case of COVID-19)?
*
Yes
No
Do you have the feeling of being feverish, have chills like when having the flu, or a fever (measured orally) with a temperature equal to or greater than 38 ° C (100.4 ° F) or, for elderly individuals, a temperature greater than 37.8 ° C (100.0 ° F)?
*
Yes
No
Do you have the feeling of being feverish, have chills like when having the flu, or a fever (measured orally) with a temperature equal to or greater than 38.1 ° C (100.6 ° F)?
*
Yes
No
Do you have a cough that’s recently started or that’s gotten worse?
*
Yes
No
Do you have a cough that’s recently started or that’s gotten worse?
*
Yes
No
Are you having difficulty breathing?
*
Yes
No
Are you having difficulty breathing?
*
Yes
No
Are you short of breath?
*
Yes
No
Are you short of breath?
*
Yes
No
Do you have a sudden loss of smell (without nasal congestion) with or without loss of taste?
*
Yes
No
Do you have a sudden loss of smell (without nasal congestion) with or without loss of taste?
*
Yes
No
Do you have a sore throat?
*
Yes
No
Do you have a sore throat?
*
Yes
No
Do you have a runny nose or nasal congestion?
*
Yes
No
Do you have a runny nose or nasal congestion?
*
Yes
No
Do you have at least 2 of the following symptoms?
*
• Headache • Intense fatigue • Muscle pain (not related to physical exertion) • Significant loss of appetite • Nausea or vomiting • Diarrhea
Yes
No
Do you have a known health condition that may explain the symptoms reported above?
*
Yes
No
Not Applicable
If yes, specify:
*
Do you have at least 2 of the following symptoms?
*
• Headache • Intense fatigue • Muscle pain (not related to physical exertion) • Significant loss of appetite • Nausea or vomiting • Diarrhea
Yes
No
Do you have a known health condition that may explain the symptoms reported above?
*
Yes
No
Not applicable
If yes, specify:
*
Have you been in close contact (at least 15 minutes within 2 meters) with a confirmed or suspected case of COVID-19?
*
Yes
No
* This condition excludes healthcare workers who have provided care to a confirmed or suspected case of COVID-19 with the appropriate personal protective equipment.
Signature of the person who completed the form:
*
Hidden
Date:
