COVID-19 ASSESSMENT

Please note that no patient will be seen in the rooms if we do not have a completed copy of this form. Please complete and submit the following form prior to your scheduled visit:

!! Alert !!

Failure to provide correct information places everyone at risk.

Please ensure your answers are truthful and accurate.

Are you a healthcare worker?

Is anyone in your household a Healthcare Worker?

Do you or anyone in your household work in a healthcare facility where patients are being treated for COVID-19?

In the past 14 days, have you been in contact with a confirmed or probable COVID-19 positive person?

Do you have a mask which you will wear in this facility at all times?

In the past 7 days, have you traveled inter-provincially?

Have you or any member of your household been seen by a doctor or health care practitioner or been admitted to hospital for any reason in the last 7 days?

Have you or anyone in your household been tested for COVID-19 in the past 7 days?

Do you have or have you had any illness in the past 14 days ?

Do you have any of the following symptoms in the last 14 days (cough / sore throat / fever / chills / headache / shortness of breath / muscle or joint pain / sinusitis / vomiting / nausea / diarrhea)?

Have you lost your sense of smell and or appetite?

Have you visited, or do you reside in an old age or retirement home?

Have you visited or received treatment at a Dialysis or Oncology center in the last 7 days?

Have you attended a funeral, religious service or other gathering in the past 7 days?

Declaration

 

The completion of this screening tool is a formal declaration that the information you provide is true and accurate. Untruthful answers place all in this facility at risk. Should it come to our attention that you misrepresented the facts we reserve the right to escalate in accordance with the COVID 19 and Disaster management regulations to the relevant authorities.

©2020 by Dr Heinrich Niemoller