108 Kingsway Mall, Edmonton, AB T5G 3A6
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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?
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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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