Patient COVID screening form

Patient Screening Form

Patient Screening Form for covid

Use this form before your appointment.
Patient Name :(Required)

Please answer the following screening questions.
Q1. Are you immunocompromised? *
Q2. Check all symptoms you have. Choose any or all that are new, worsening and not related to other known causes or conditions. **
Q3. Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other government authority) that you should currently be quarantining, isolating or stay at home?
Q4. In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing kit?

When you arrive at the office, you will be asked to :
  • Sanitize your hands.
  • Have your temperature taken.

* Factors such as old age, diabetes and end-stage renal disease are generally not considered immunocompromised. Examples of being immunocompromised include individuals:
  • undergoing cancer chemotherapy
  • with untreated HIV infection with CD4 T lymphocyte count less than 200
  • with combined primary immunodeficiency disorder
  • on prednisone medication - more than 20 mg per day (or equivalent) for more than 14 days
  • on other immune suppressive medications

** select "NO" if all of these apply :
  • you do not have a fever, AND
  • your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea)