Bramptom

VIRTUAL WAITING ROOM

PLEASE FILL IN THE FORM AND SUBMIT TO ENTER OUR VIRTUAL WAITING ROOM.

WAIT FOR OUR CALL TO COME INTO THE OFFICE FOR YOUR SCHEDULED APPOINTMENT. THE FORM MUST BE SUBMITTED SO WE KNOW YOU ARE HERE. THE ACCOMPANYING PERSON MUST FILL IN THE FORM AS WELL.

****Brampton Waiting room***

COVID-19  - Patient Pre-Screening Questionnaire
Have you been in close contact with anyone with acute respiratory illness in the last 14 days?
Has the patient travelled or been in contact with anyone who has travelled outside Ontario in the past 14 days?
Has the patient been diagnosed with COVID 19?
Has the patient had close contact with a confirmed case of COVID-19?
Does the patient have a fever?
Does the patient have a new cough?
Does the patient have a worsening chronic cough?

Does the patient have shortness of breath?
Does the patient have difficulty breathing?
Does the patient have a sore throat?
Does the patient have difficulty swallowing?
Has the patient had a recent loss of taste or smell?
Does the patient have chills?
Does the patient have unexplained headaches?
Does the patient have unexplained fatigue/malaise/muscle aches (myalgias)?
Does the patient have nausea/vomiting?
Does the patient have diarrhea?
Does the patient have abdominal pain?
Does the patient have pink eye?
Does patient have an unexplained runny nose/nasal congestion?
If the patient is over 70 years old, are they experiencing any of the following symptoms: delirium, unexplained or increased numbers of falls, acute functional decline, or worsening of chronic conditions?
Please check the boxes which apply to the person accompanying the patient to the appointment
Virtual Waiting Room

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