Advance Endoscopy & Specialist Center,
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COVID-19 Assessment Form
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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
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