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? * ---YesNo

Have you been diagnosed with COVID-19? * ---YesNo

Have you had close contact with a confirmed case of COVID-19? * ---YesNo

Do you have any of the following potential signs or symptoms of COVID-19:

• Fever or chills? * ---YesNo

• New cough, worsening chronic cough, shortness of breath or difficulty breathing? * ---YesNo

• Sore throat or difficulty swallowing? * ---YesNo

• Decrease or loss of smell or taste? * ---YesNo

• Headache? * ---YesNo

• Unexplained fatigue/malaise/muscle aches (myalgia) or lethargy? * ---YesNo

• Nausea, vomiting, diarrhea or abdominal pain? * ---YesNo

• Pink eye (conjunctivitis)? * ---YesNo

• Runny nose or nasal congestion without known cause? * ---YesNo

Have you been diagnosed with pneumonia? * ---YesNo

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