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(905) 218-6556
Call Now!
(905) 218-6556
341 Beach Blvd, Hamilton, ON
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Ontario Ministry of Health COVID-19 Patient Screening Form
To be completed ON THE DAY OF YOUR APPOINTMENT only
Please only complete the Ontario Ministry of Health Patient COVID-19 screening ON THE DAY OF YOUR APPOINTMENT. Unfortunately, we are unable to accept screening questionnaires completed the evening before your appointment. We are sorry for the inconvenience.
Name
*
First
Last
Today's Date
*
MM slash DD slash YYYY
Have you received your second vaccination dose?
*
Yes
No
In the last 10 days, has someone you live with:
*
Been sick with symptoms associated with COVID-19?
Tested positive for COVID-19 on a PCR or rapid antigen test?
No one in my household has symptoms of COVID-19 or has tested positive for COVID-19 in the last 10 days.
In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit?
*
Yes
No
In the last 10 days, have you been identified as a "close contact" of someone who currently has COVID-19?
*
Yes
No
Have you been told you should be isolating?
*
Yes
No
Have you travelled outside of Canada in the last 10 days?
*
Yes
No
COVID-19 Symptom Screening (please check any that apply)
Fever and/or chills
New cough or barking cough
Shortness of breath
Decrease or loss of sense of taste or smell
Muscle aches / joint pain
Extreme tiredness
Sore throat
Runny nose with unknown cause
New or unusual headache
Nausea, vomiting and/or diarrhea
In the last 10 days I have not experienced COVID-19 symptoms, travelled outside of Canada, tested positive for COVID-19 or been in close contact with a confirmed or suspected case of COVID-19
If you do not have any COVID-19 symptoms or risk factors please confirm this by checking the negative screening statement below.
NEGATIVE SCREENING STATEMENT
I confirm that I have reviewed the COVID-19 symptoms and risk factors carefully and none apply to me.
