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? Yes No 2) Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? Yes No 3) Do you have any of the following symptoms?Fever: Yes No New onset of cough or Worsening Chronic cough: Yes No Shortness of breath: Yes No Difficulty breathing: Yes No Sore throat: Yes No Difficulty swallowing: Yes No Decrease or loss of sense of taste or smell: Yes No Chills: Yes No Headaches: Yes No Unexplained fatigue/malaise/muscle aches: Yes No Nausea, vomiting, diarrhea, abdominal pain: Yes No Pink eye (conjunctivitis): Yes No Runny nose/nasal congestion without other known cause: Yes No 4) 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? Yes No If “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.