COVID-19 SELF-SCREENING QUESTIONNAIRE

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Downtown Medical Clinic

Home
About Us
- About
- Our Team
- Policy
Online Booking
Services
Clinic-Update
Registration Forms
Contact Us

Call us today 403-454-6199

Downtown Medical Clinic

Call us today 403-454-6199

Overview

This form should be completed prior to each clinic visit. If an individual answer YES to any of the questions, virtual care would be offered if appropriate.

Individuals with fever, cough, shortness of breath, runny nose, or sore throat, are required to isolate for 10 days per CMOH Order 05-2020 unless they receive a negative COVID-19 test and are feeling better.

Name *

First

Last

Email *

Please enter your email, so we can follow up with you.

Phone number *

Fever *

Cough *

Shortness of breath / difficulty breathing *

Runny nose *

Sore throat *

Chills *

Painful swallowing *

Nasal Congestion *

Feeling unwell / fatigued *

Nausea / vomiting / diarrhea *

Unexplained loss of appetite *

Loss of sense of taste or smell *

Muscle/ joint aches *

Headache *

Conjunctivitis (commonly known as pink eye) *

Have you travelled outside of Canada in the last 14 days? *

Have you had close contact with a confirmed case of COVID-19 in the last 14 days? *

Have you had close contact with an individual who has any one of the first 5 symptoms on this list AND who is a close contact of a confirmed case of COVID-19 in the last 14 days? *

Are you unable to wear a face mask through out your visit to the clinic? *