Hospice Orillia COVID-19 Screening Tool

COVID-19 Self Screening Questions

Name (if completing for a client please enter first name only):

Completed by:

Your Email (required)

__________________________________________________________________________________________

Are you or anyone in your household currently experiencing any of the following symptoms?:

- Fever and/or chills (temperature 37.8 degrees C or higher)
- Cough or barking cough (continuous, more than normal)
- Shortness of breath (out of breath, can’t breathe deeply)
- Decrease or loss of smell or taste
- Muscle aches/joint pain (unusual or long lasting)
- Extreme tiredness
- Sore throat (painful swallowing)
- Runny or stuffy/congested nose (not related to cold weather, allergies)
- Headache (unusual or long lasting)
- Nausea, vomiting, diarrhea

Are you or anyone in your household:
- Isolating because of a positive COVID-19 test (rapid antigen, molecular or home-based self testing
kit)?
- Experiencing COVID-19 symptoms, waiting for test results, or have been told by a healthcare
provider to self-isolate?
Please confirm:
Myself, and all members of my household, answered “NO” to all of the above questions.Myself, and all members of my household answered “YES” to one or more of the above questions. Therefore, I understand that my visit will be cancelled and rescheduled to a later date.
Please press send regardless of your answers. NOTE: If you answered "YES" to any of the above questions, THE VISIT WILL BE CANCELLED. Call Daniela Accomando at 705-325-0505 x 118 or Stefanie Collins at 705-325-0505 x 211 as soon as possible. Hospice Orillia recommends, in accordance with the guidelines set forth by the Government of Ontario, that those who are experiencing symptoms of COVID-19 should isolate at home, and complete testing where possible. If you answered "NO" to all questions, have a great visit!