COVID-19 Patient Prescreening Questionnaire

Patient name:*
Phone*
Email*
I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.
INITIAL BELOW*
PRE-SCREENING QUESTIONS:
1. Do you have a fever of have felt hot or feverish anytime in the last 10 days?*
- Yes
- No
2. Do you have any of these symptoms: New or worsening cough? New or worsening shortness of Breath? Difficulty breathing? Sore throat or painful swallowing? Runny nose?*
- Yes
- No
3. Have you experienced a recent loss of smell or taste?*
- Yes
- No
4. Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?*
- Yes
- No
5. Have you returned from travel outside of Alberta in the last 14 days?*
- Yes
- No
If you answered "yes" to number 5 - where did you travel to?
6. Is your workplace considered high risk?*
- Yes
- No
PATIENT VULNERABILITY:
7. Are you over the age of 65?*
- Yes
- No
8. Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?*
- Yes
- No
SIGNATURE OF PATIENT/GUARDIAN*
Printed Name*
Date*

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