COVID-19 SCREENING FORM Order Number Patient's Name * Date * Have you previously been diagnosed with COVID-19, or do you think you’ve had/have COVID-19? * YES NO When and how were you confirmed positive? * I think I had it. I had a positive nasal swab test. I had a positive blood test. I had a positive saliva test. I currently have symptoms and am waiting for a test. How were you confirmed negative? * I was diagnosed negative by a nasal swab test. I show antibodies to COVID-19 with a blood test. My doctor said I longer have it because I don’t have any symptoms. I don’t have any symptoms, so I don’t have it. When were you confirmed negative? * 24 hours ago Today 10 days after testing Do you currently have (or have you experienced) any of the following symptoms in the past 21 days: Fever * YES NO Fatigue (feeling tired) * YES NO Altered or loss of taste/smell * YES NO Dry cough * YES NO Trouble breathing * YES NO Shortness of breath, difficulty breathing, chest tightness * YES NO Blueish lips or face * YES NO Chills/repeated shaking with chills * YES NO Muscle pain * YES NO Headache or sore throat * YES NO Any other flu-like symptoms * YES NO GI upset or diarrhea * YES NO Are you in contact with anyone who has been sick and/or confirmed to be COVID-19 positive? * YES NO In the past 14 days have you traveled outside of Canada? * YES NO Are you over age 65? * YES NO Do you have diabetes? * YES NO Do you have respiratory problems? * YES NO Do you have any autoimmune disorders? * YES NO Are there any other conditions you would like to report?
