COVID – 19 Pre- Screening Form Patient Name* First Name Last Name 1. Do you have a fever or have you felt hot or feverish anytime in the last 10 days?YesNo2. Do you have any of these symptoms: New or worsening cough? New or worsening shortness of breath? Difficult breathing? Sore throat or painful swallowing? Runny nose?YesNo3. Have you experienced a recent loss of smell or taste?YesNo4. Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?YesNo5. Have you returned from travel outside of Canada in the last 14 days?YesNo6. Have you returned from travel within Canada from a location known affected with COVID-19 in the last 14 days?YesNo7. Is your workplace considered high risk?YesNo8. Are you over the age of 65?YesNo9. Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?YesNoNameThis field is for validation purposes and should be left unchanged.