Patient Screening Form (Please fill online and send to the office on the day of your appointment) Patient Name:Patient Age:Please answer the following Screening Questions:1) Have you travelled outside of Canada in the past 14 days?YesNo2) Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?YesNo3) Do you have any of the following symptoms?Fever:YesNoNew onset of cough or Worsening Chronic cough:YesNoShortness of breath:YesNoDifficulty breathing:YesNoSore throat:YesNoDifficulty swallowing:YesNoDecrease or loss of sense of taste or smell:YesNoChills:YesNoHeadaches:YesNoUnexplained fatigue/malaise/muscle aches:YesNoNausea, vomiting, diarrhea, abdominal pain:YesNoPink eye (conjunctivitis):YesNoRunny nose/nasal congestion without other known cause:YesNo4) If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?YesNoIf “yes” to any of the above questions, please call our office before you come to your appointment. Non-emergency appointments will be rescheduled. Remember when you arrive at the office, you will need to wear a mask, sanitize your hands, and have your temperature taken. Do not forget to complete our COVID-19 Risk Acknowledgement form next. Thank you.