Screening Questionnaire

Please provide details prior to your next appointment.

  • Date
  • YYYY dash MM dash DD
  • Personal Information
  • Screening Questions

    Did the person have close contact with anyone with acute respiratory Illness or travel outside of the National Capital Region* in the past 14 days?

    * includes both sides of the Ottawa river in Ontario & Quebec.

  • Does the person have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?

  • Does the person have any of the following symptoms:

    You can choose more than one.

  • If the person is 70 years of age or older, are they experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?

  • Patient Declaration

    I/We hereby confirm that the information provided herein is accurate, correct and complete and that the documents submitted along with this application form are genuine.

  • Verification

    Please enter any two digits*


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