COVID-19 Screening form

COVID-19 Screening

Note: Personal information is being collected by Kemptville District Hospital for COVID-19 screening purposes.
**Required fields are indicated with an asterisk (*)**

Personal information

First Name *
Last Name *
Email Address *
Date of Birth *
Surgery Date
Surgeon *

Please answer Yes or No to each of the following

Have you travelled outside of Canada in the last 14 days? *
In the last 10 days, have you been diagnosed with COVID-19? *
In the last 10 days, have you had close contact with a confirmed case of COVID-19? *
Do you have any of the following potential signs or symptoms of COVID-19:

Fever or chills? *
New cough, worsening chronic cough, shortness of breath or difficulty breathing? *
Decrease or loss of smell or taste? *
Unexplained fatigue/malaise/muscle aches (myalgia) or lethargy? *
Nausea, vomiting, diarrhea or abdominal pain? *

Have you recently been diagnosed with pneumonia? *

Have you been diagnosed with unexplained tachycardia, decreased blood pressure or hypoxia? *

Are you having a Colonoscopy or gastroscopy procedure? *

Are you fully vaccinated with a Health Canada approved vaccine? (fully vaccinated: two doses of Health Canada approved vaccine greater than 14 days ago; approved vaccines: Pfizer, Moderna, Astra Zeneca, Johnson & Johnson) *

If you answered No to the previous question, KDH strongly recommends that you have a COVID-19 PCR test up to 72 hours before your surgery. You can go to your local testing facility and state that you are having surgery and need a test. On the day of your surgery, you will be asked to attest that you have had a COVID test and/or to sign a waiver.

Please check this box to acknowledge that you have read this information.