Riverbend Screener

Name(Required)

First Last

Phone(Required)

Email(Required)

Date of Birth(Required)

1.) Have you received your final (or second) Covid-19 Vaccinations more than 14 days ago?(Required)

Yes

No

A fully immunized individual is defined as any individual >14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series (i.e .Johnson and Johnson).

2) Have you travelled outside of Canada in the past 14 days AND been advised by a doctor, health care provider or public health unit to self-isolate (staying at home)?(Required)

Yes

No

3) Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE in the past 14 days?(Required)

Yes

No

4.) Do Any of the following apply

A.) You live with someone who is currently isolating because of a positive COVID-19 test(Required)

Yes

No

B) You live with someone who is currently isolating because of COVID-19 symptoms(Required)

Yes

No

C) You live with someone who is waiting for COVID-19 test results(Required)

Yes

No

5.) Do you have any of the following Symptoms

A.) Fever and/ or chills(Required)

Yes

No

B.) New onset of cough or worsening chronic cough?(Required)

Yes

No

C.) Shortness of breath?(Required)

Yes

No

D.) Decrease or loss of sense of taste or smell?(Required)

Yes

No

6.) Please answer the following questions

A.) I am an adult (18 years or older) or completing on behalf of an adult who has problems with vision or cognition, and I (or the person entering the clinic) has unexplained fatigue/lethargy/malaise/muscle aches.(Required)

Yes

No

B.) I am completing this form on behalf of a child (under 18 years old), and they have nausea/vomiting, diarrhea(Required)

Yes

No

Name and Phone Number of the individual that is completing this screening form.

Name(Required)

First Name Last Name

First name and last name of individual completing this screening form

Phone(Required)

Phone Number of the individual completing this screening form.

7.) Have you tested positive for COVID-19 in the past 10 days or have been told you should be isolating?(Required)

Yes

No

By pressing submit, I attest that, to the best of my knowledge and belief, all information in the above referenced Patient COVID Screening is accurate and complete.