COVID-19 Patient Screening

Please answer the following questions to ensure you are COVID-19 symptom free.

Patient Name *

Patient Age *

1. Do you have a fever (greater than 38ºC) or feverish chills, sweats, muscle aches, light-headedness? *

Yes

2. Do you have a new or worsening cough? *

Yes

3. Do you have a new or worsening sore throat (difficulty swallowing)? *

Yes

4. Do you have a new or worsening shortness of breath? *

Yes

5. Do you have a new or worsening runny nose? *

Yes

6. Do you have a new or worsening headache? *

Yes

7. Have you been in close personal contact, without PPE, with a suspected or confirmed COVID-19 patient within the past 2 weeks? *

Yes

8. Have you travelled outside of Nova Scotia (by air, car, bus or otherwise) in the past 2 weeks? *

Yes

9. Are you older than 60? *

Yes

10. Do you have any of the following medical condition which would put you in a high-risk category: diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised, having active malignancy? *

Yes

11. Have you travelled outside of Atlantic Canada within the past 14 days? *

Yes

12. Has anyone in your household travelled outside Atlantic Canada in the last 14 days? *

Yes

13. Are you required for any reason to be self-isolating? *

Yes

The province of Nova Scotia has provided a list of COVID Exposures at Locations across Halifax at this link: https://www.nshealth.ca/news/nova-scotia-health-public-health-advises-covid-exposures-locations-across-halifax

14. Please check this list carefully and confirm you have not been to any of these locations at the specified times. *

No, I have not been to any of these locations

Yes, I have been to one of these locations

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