Covid Prescreen Form

Name :* 

DATE:

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?

Your Appointment Request was submitted. We will be in touch shortly!

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