Patient Screening Form

Patient Name *

Date *

It is important to closely monitor your health and the health of those you care for to help prevent the spread of COVID-19 and other illnesses like the flu.

1. Do You Feel Sick? *

Yes

No

2. In the past 48 hours, have you had, or are you currently experiencing;

Cough (New or Worsening) *

Yes

No

OR two or more of the following symptoms (new or worsening);

Fever (i.e. chills/sweats) *

Yes

No

Sore Throat *

Yes

No

Runny nose/nasal congestion *

Yes

No

Headache *

Yes

No

If yes, go home or stay home as noted above. Follow Public Health instructions for testing and isolation.

3. Have you recently visited a COVID-19 exposure site? *

Yes

No

4. Have you travelled in the past 14 days outside of the province and/or country AND been advised to self-isolate? *

Yes

No

5. Optional: Are you fully vaccinated against COVID-19? Fully vaccinated means that it has been at least 14 days since you received the second dose of the Pfizer, Moderna, or AstraZeneca COVID-19 vaccine or the Janssen COVID-19 vaccine. *

Yes

No

Prefer not to answer

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Surrey COVID-19 Patient Screening

New Patients Welcome