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

In the last 10 days, have you been diagnosed with COVID-19? * ---YesNo

In the last 10 days, 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

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

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

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

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

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

Are you having a Colonoscopy or gastroscopy procedure? * ---YesNo

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) * ---YesNo

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.