COVID-19 Patient Pre-Screening Questionnaire First name:*Last name:*Phone*Email* I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious.INITIAL BELOW*PRE-SCREENING QUESTIONS:1. Do you have a fever of have felt hot or feverish anytime in the last 10 days?* Yes No 2. Do you have any of these symptoms: New or worsening cough? New or worsening shortness of Breath? Difficulty breathing? Sore throat or painful swallowing? Runny nose?* Yes No 3. Have you experienced a recent loss of smell or taste?* Yes No 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?* Yes No 5. Have you returned from travel outside of Alberta in the last 14 days?* Yes No If you answered "yes" to number 5 - where did you travel to?6. Is your workplace considered high risk?* Yes No PATIENT VULNERABILITY:7. Are you over the age of 65?* Yes No 8. Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?* Yes No Please explain if you answered yes to question #8SIGNATURE OF PATIENT/GUARDIAN*Printed Name*Date*Untitled
