COVID-19 Screening Questions - Grand River Sports Medicine Centre serving Cambridge and Kitchener

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COVID-19 Screening

Please complete this form on the same day of your appointment.

I have an appointment at

Name of Patient (required)

Date of Birth (required)

If patient is under 18 years of age, Name of Parent/Guardian

Relationship

I certify that I am the parent or legal guardian of the above minor. I certify that I am over 18 years of age.

Did you travel outside of Ontario or Canada in the past 14 days?

Yes No

Did you have a confirmed case of Covid-19 or had close contact with a confirmed case of Covid-19?

Yes No

Are you or is someone in your household waiting for COVID-19 test results?

Yes No

Do you any of the following symptoms (please check all that apply)?

Fever New onset of cough Worsening chronic cough Shortness of breath Difficulty breathing Sore throat Difficulty swallowing Decrease of loss of sense of taste or smell Runny nose or nasal congestion without other known cause Chills Headaches Unexplained fatigue/malaise/muscle aches (myalgias) Nausea/vomiting, diarrhea, abdominal pain Pink eye (conjunctivitis) NONE OF THE ABOVE

** If you are over 70 ** Are you experiencing any of the following: delirium, falls, acute functional decline, or worsening of chronic conditions?

Yes No

Read, Understand, Consent and Agree

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. You also understand that although GRSM has put strict procedures in place to reduce the potential transmission of the COVID-19 virus, there are inherent risks in choosing to enter the clinic.

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Cambridge:

40 George Street North
(519) 622-4529
cambridge@grsm.ca

KITCHENER:

700 Strasburg Road
(519) 571-7111
kitchener@grsm.ca

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