COVID19 virus

COVID-19 PATIENT SCREENING CHECKLIST:

Printable Version

In order to enter the clinic for any reason you must meet the following conditions:

1) Complete and sign the COVID-19 Screening Checklist below
2) Wear a mask/scarf
3) Attend alone – no visitors unless you require one personal care provider
4) Do not arrive early – no more than 5 minutes before your appointment
5) Do not wear gloves – you will be required to sanitize your hands

Patients who wish to shorten their screening time, may complete this COVID-19 Checklist before arriving at the building for their appointment and provide it to the screening team at the front entrance.    The Checklist must be completed within two hours of attending the clinic.   Checklists will be kept strictly confidential by the Arnprior & District Family Health Team.

Do not come to the clinic if you answer “yes” to ANY of these questions.

Circle YES or NO for each question

Q1: Did you have close contact with anyone with acute respiratory Illness or travelled outside of Ontario in the past 14 days? YES / NO

Q2: Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?   YES / NO

Q3: Do you have any of the following symptoms?: YES / NO

  • Fever
  • New onset of cough
  • Worsening chronic cough
  • Shortness of breath
  • Difficulty breathing
  • Sore throat
  • Difficulty swallowing
  • Decrease loss of sense of taste or smell
  • Chills
  • Headache
  • Unexplained fatigue/malaise/muscle aches
  • Nausea/vomiting/diarrhea/abdominal pain
  • Pink eye(conjunctivitis)
  • Runny nose/nasal congestion without other known cause

Q4: If you are 70 or over – 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 response to ALL of the screening questions is NO: You have screened negative for COVID and can attend your appointment.

Do not come to the clinic if you answer “yes” to ANY of these questions. Please call your doctor’s office to discuss rescheduling your appointment or other actions to take.

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