Advance Endoscopy & Specialist Center,
info@advanceendoscopy.com
Mon - Sat: 7:30 AM - 04:00 PM
Book An Appointment
Home
About Us
Procedures
For Patients
Instructions for Procedures
Gastroscopy Instructions
Colonoscopy Instructions
Flexible Sigmoidoscopy
Instruction
General Information
Irritable Bowel Syndrome (IBS)
Constipation
Diverticular Disease
Anal Stenosis
Anusitis/Pruritis Ani
Anal Fissures, Fistulas
and Lesions
Forms
Reach Us
Mon - Sat: 7:30 AM - 04:00 PM
info@advanceendoscopy.com
Book An Appointment
COVID-19 Assessment Form
Home
COVID-19 Assessment Form
COVID-19 ASSESSMENT FORM
Patient Information
Name
Date of birth
HC #
Gender
Male
Female
Address
Phone Number
Select Advance Endoscopy & Specialist Center Region
Mississauga
Toronto
Bowmanville
Recent Travel History (within 1 month):
Travel To
Date of Travel
Date of Return
Exposure History
Exposure to Confirmed COVID-19 case
Yes
No
Details
Please indicate if you are having any of the following symptom as:
Chills/ Fever (Temp. 37.8 C or greater)
Yes
No
New or worsening Cough/ Nasal Congestion
Yes
No
Sore Throat
Yes
No
Fatigue
Yes
No
Chest Tightness/Pressure
Yes
No
Shortness of Breath (Dyspnea)
Yes
No
Runny Nose/ Nasal congestion
Yes
No
Headache
Yes
No
Nausea/Vomiting/ Abdominal pain
Yes
No
Diarrhea /Cramps
Yes
No
Sudden Loss of Smell/Taste Taste disorder
Yes
No
Difficulty swallowing
Yes
No
Atypical Symptoms
Malaise/myalgias - Acute functional decline
Delirium (acutely altered mental status and inattention) - Croup
Unexplained or increased number of falls - Conjunctivitis Exacerbation of chronic conditions
Other
Other
Patient's Name
Patient's Signature and date
If you are human, leave this field blank.
Submit
Δ
X