COVID-19

Self Assessment Tool

COVID-19

Please complete the following COVID-19 self assessment questionnaire prior to your next visit at.

Name

Phone

Are you experiencing any of the following:
• Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)
• Severe chest pain
• Having a very hard time waking up
• Feeling confused
• Losing consciousness
• Mild to moderate shortness of breath
• Inability to lie down because of difficulty breathing
• Chronic health conditions that you are having difficulty managing because of difficulty breathing

Answer

Yes No

Are you experiencing cold, flu or COVID-19-like symptoms, even mild ones?
Symptoms include: fever, chills, cough, shortness of breath, sore throat and painful swallowing, stuffy or runny nose, loss of sense of smell, headache, muscle aches, fatigue or loss of appetite.

Answer

Yes No

Have you travelled to any countries outside Canada (including the United States) within the last 14 days?

Answer

Yes No

Did you provide care or have close contact with a person with confirmed COVID-19?
Note: This means you would have been contacted by your health authority’s public health team

Answer

Yes No

3961 Hastings Street

604 291 6666

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COVID-19

Self Assessment Tool

COVID-19

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