COVID Screening

COVID SCREENING

Please Select Location
Mississauga - MillcreekMilton

Patient Name

Date

Essential Visitors
Essential visitors include a person:
• performing essential support services (e.g., food delivery, phlebotomy, maintenance,
family providing care and other health care services required to maintain good health);
OR
• visiting a very ill or palliative resident.

Screening Questions
1. Do you have any of the following new or worsening symptoms or signs?

New or worsening cough
YesNo

Shortness of breath
YesNo

Sore throat
YesNo

Runny nose, sneezing or nasal congestion
(in absence of underlying reasons for symptoms such as
seasonal allergies and post nasal drip)
YesNo

Hoarse voice
YesNo

Difficulty swallowing
YesNo

New smell or taste disorder(s)
YesNo

Nausea/vomiting, diarrhea, abdominal pain
YesNo

Unexplained fatigue/malaise
YesNo

Chills
YesNo

Headache
YesNo

2. Have you travelled outside of Canada or had close contact with anyone that has travelled outside of Canada in the past 14 days?
YesNo

3. Do you have a fever?
YesNo

4. Have you had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19?
YesNo

5. Did you wear the required and/or recommended PPE according to the type of duties you were performing (e.g., goggles, gloves, mask and gown or N95 with aerosol generating medical procedures (AGMPs)) when you had close contact with a suspected or confirmed case of COVID-19?
YesNo