top of page

COVID-19 Patient Screening Guidance Document (Version 4.0 – June 11, 2020)

Be advised, the self-assessment is only meant as an aid and cannot diagnose you. Consult a health care provider if you have medical questions.

This screening tool is based on the latest COVID-19 case definitions and the Coronavirus disease (COVID-2019) situation reports published by the World Health Organization. This document should be used to screen people who are suspected or confirmed of having COVID-19 throughout the health and emergency response system. Ensuring all health providers are following the same screening protocol will help ensure consistency when dealing with suspected or confirmed cases of COVID-19.

** Please be advised this application will be kept in your records, and Belle femme Clinic reserves the right to refuse Service to patients without filling this application.

COVID-19 Patient Screening Guidance :

• This checklist provides basic information only for COVID-19 screening and should be used with applicable health sector or service-specific guidance and training documents. It is not intended to take the place of medical advice, diagnosis, or treatment.

• The screening result is not equivalent to a confirmed diagnosis of COVID-19.

• At a minimum, the following questions should be used to screen for COVID-19 and can be adapted based on need/setting.

• This information is current as of the date effective and may be updated as the situation on COVID-19 continues to evolve according to the evidence, including data received from surveillance testing initiatives.

• Once the person has been screened as positive (answered YES to a question), additional COVID-19 screening questions may discontinue.

• In the event a hospital emergency department modifies or adds COVID-19 screening questions, they should alert the local paramedic's services of any changes.

Covid-19 Health Declaration

How are you feeling today?

Thanks for submitting!

• 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

• Chills

• Headaches

• Unexplained fatigue/malaise/muscle aches (myalgias)

• Nausea/vomiting, diarrhea, abdominal pain

• Pink eye (conjunctivitis)

• Runny nose or nasal congestion without other known cause

For more information and Covid-19 Concerns please contact Telehealth Ontario: 1-866-797-0000  and Incase of facing  Emergency please contact 911 .



bottom of page