Patient / Visitor Screening Form

Before coming to hospital you may complete your screening online or print a copy to show at your clinical point of destination.

You will receive a “red” or “green” result after completing this form. Please follow the instructions provided.

Email Address ***
Please re-enter your email address ***
Are you a Patient or a Visitor? * Patient Visitor
Have you travelled outside of Canada in the past 21 days? * Yes No N/A
Have you had close contact with someone who is symptomatic, awaiting COVID results, or isolating within the last 10 days? * Yes No N/A
Have you had close contact with a confirmed case of COVID-19 within the last 10 days? * Yes No N/A
Have you tested positive for COVID-19 in the last 10 days? * Yes No
Do you have a new / worsening cough? * Yes No
Do you have shortness of breath / difficulty breathing? * Yes No N/A
Have you had fever (37.8 or greater) and/or chills in the last 48 hours? * Yes No
Loss/decrease of sense of taste or smell? * Yes No
Extreme Fatigue * Yes No
Sore throat * Yes No
Headaches * Yes No
Gastrointestinal symptoms (i.e. vomiting or diarrhea) * Yes No
Muscle aches/joint pain * Yes No
Runny nose or nasal congestion * Yes No
SymptomCountForm **
I acknowledge and confirm that the information provided above is truthful and accurate. * Yes No
I have read and understood the above statements. * Yes No

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