Ministry of Health COVID-19 Patient Screening Guidance Document V. 4.0, June 11, 2020

This screening tool is based on the latest COVID-19 case definitions and the Coronavirus disease (COVID-2019) situation reports published by the World Health Organization. This document should be used to screen people who are suspected or confirmed of having COVID-19 throughout the health and emergency response system. Ensuring all health and safety providers are following the same screening protocol will help ensure consistency when dealing with suspected or confirmed cases of COVID-19.

In order to ensure the health and safety of our patients and staff, you are required to complete the Ontario Public Health COVID-19 screening tool. Please read through the screening questions below and at the end of the document indicate your selection.

Q1: Have you traveled outside of Canada in the past 14 days?

Q2: Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

Q3: Do you have any of the following symptoms:

Fever
New onset of cough
Worsening chronic cough
Shortness of breath
Difficulty breathing
Sore throat
Difficulty swallowing
Decrease or loss of sense of taste or smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause

Q4: If you are 70 years of age or older, are you experiencing any of the following symptoms:
Delirium
Unexplained or increased number of falls
Acute functional decline
Worsening of chronic conditions

By selecting the "Send" button, I acknowledge that I have answered the above questions honestly. I acknowledge that I am signing this screening electronically. I agree that my electronic signature on this document is the equivalent of my manual/handwritten signature.

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