New Patient Package: Patient Screening Form

    Patient Screening Form


    Who answered:
    If Other, Specify the name:

    How to Contact:

    Screening Questions


    1. Are you currently waiting for the results of a COVID-19 test?
    Pre-Screen

    2. Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Sneezing? Post-nasal drip?
    Pre-Screen

    3. Have you experienced a recent loss of smell or taste?
    Pre-Screen

    4. Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?
    Pre-Screen

    5. Have you returned from travel outside of Canada in the last 14 days?
    Pre-Screen

    6. Have you returned from travel within Canada from a location known affected with COVID-19?
    Pre-Screen

    7. Is your workplace considered high risk?
    Pre-Screen

    Patient Vulnerability


    8. Are you over the age of 70?
    Pre-Screen

    9. Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?
    Pre-Screen

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    3488 West Broadway

    Vancouver, BC, V6R 2B3

    604-336-0958

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