COVID19 Screen




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:

    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
    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:
    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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