Covid Prescreen Form

Name :* 


Patient Screening Questions - Covid-19

1.) Do you have any of the following symptoms:

  • Fever/chills

  • Shortness of Breath/Chest pain

  • Sore throat

  • Dry cough

  • Congestion

  • Drowsiness

  • Loss of consciousness/confusion

2.) Have you been in contact with someone known to have tested positive with COVID-19?

3.) Have you had any contact with laboratory samples known to contain COVID-19?

4.) Have you been in a large group setting in Manitoba in the last 14 days?

5.) Have you traveled outside of Manitoba in the last 14 days?

6.) Are you or someone you live with a health care worker/first responder?

7.) Do you or someone you live with work in a correctional facility,shelter,personal care home?

8.) Has a member of your household been identified as a close-contact and instructed to self-isolate (quarantine) by public health officials,and they are not able to isolate from you?

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If you have any questions, please call our office at 204-837-4517.