COVID Screening Form - Kirby IP Canada

Please complete the following questions before visiting our office.

Name

First Last

Do you have any of the following new or worsening symptoms?

Fever/Chills

Yes
No

Cough

Yes
No

Difficulty breathing/ Shortness of breath

Yes
No

Sore throat/ Difficulty swallowing

Yes
No

Runny nose (unrelated to seasonal allergies)

Yes
No

Loss of taste or smell

Yes
No

Not feeling well, headache, unexplained tiredness and muscle aches

Yes
No

Nausea, vomiting, diarrhea, abdominal pain

Yes
No

In the last 14 days, have you had close physical contact with a person who (a) was sick with a respiratory illness (had a new or worsening cough, fever or difficulty breathing)? (b) has returned from travel outside of Canada in the last 14 days? (c) was a confirmed or probable case of COVID-19?

Yes
No

In the last 14 days, have you travelled outside of Canada?

Yes
No

This screening survey has been created in line with Ottawa Public Health’s recommendations for employers. By completing this survey, you help us reduce the health risks to those in the office. The responses are confidential and will only be seen by the Partners and Michelle Hatcher.*

I understand

If you answered YES to any of these questions, please return home and self-isolate. Visit OttawaPublicHealth.ca/COVIDCentre for more information about getting tested. If you are feeling unwell, contact your health care provider or call Telehealth Ontario at 1-866-797-0000 to speak to a registered nurse.