Patient Screening Form

Patient Name *

Patient Age *

1. Do you have a fever (greater than 38ºC) or feverish chills, sweats, muscle aches, light-headedness? *

Yes

No

2. Do you have a new or worsening cough? *

Yes

No

3. Do you have a new or worsening sore throat (difficulty swallowing)? *

Yes

No

4. Do you have a new or worsening shortness of breath? *

Yes

No

5. Do you have a new or worsening runny nose? *

Yes

No

6. Do you have a new or worsening headache? *

Yes

No

7. Have you been in close personal contact, without PPE, with a suspected or confirmed COVID-19 patient within the past 2 weeks? *

Yes

No

8. Have you travelled outside of Nova Scotia (by air, car, bus or otherwise) in the past 2 weeks? *

Yes

No

9. Are you older than 60? *

Yes

No

10. Do you have any of the following medical condition which would put you in a high-risk category: diabetes, cardiovascular disease, hypertension, lung diseases including moderate to severe asthma, being immunocompromised, having active malignancy? *

Yes

No

11. Have you travelled outside of Nova Scotia, Prince Edward Island or Newfoundland/Labrador within the past 14 days?* *

Yes

No

*Rotational workers (a rotational worker is someone who lives in Nova Scotia and travels to work in another Canadian Province or territory or outside Canada on a regular schedule up to 4 weeks home at a time) are allowed to attend necessary (urgent and routine) medical appointments. This includes physicians and nurse practitioners, dentists, optometrists, and other regulated health professionals where in-person treatment is required. Rotational workers need to self-isolate for the period of time they’re in the province (up to 14 days) and follow the Health Protection Act Order and the Directive Under the Authority of the Chief Medical Officer of Health – COVID-19 Exceptions for Rotational Workers (PDF 483 KB).

12. Has anyone in your household travelled outside of Nova Scotia, Prince Edward Island or Newfoundland/Labrador in the last 14 days *

Yes

No

13. Are you required for any reason to be self-isolating? *

Yes

No

The province of Nova Scotia has provided a list of COVID Exposures at Locations across Halifax at this link: https://www.nshealth.ca/news/nova-scotia-health-public-health-advises-covid-exposures-locations-across-halifax

14. Please check this list carefully and confirm you have not been to any of these locations at the specified times. *

No, I have not been to any of these locations

Yes, I have been to one of these locations

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