COVID-19 ASSESSMENT FORM Patient Information Name Date of birth HC # Gender Male Female Address Phone Number Select Advance Endoscopy & Specialist Center Region MississaugaTorontoBowmanville Recent Travel History (within 1 month): Travel To Date of Travel Date of Return Exposure History Exposure to Confirmed COVID-19 case Yes No Details Please indicate if you are having any of the following symptom as: Chills/ Fever (Temp. 37.8 C or greater) Yes No New or worsening Cough/ Nasal Congestion Yes No Sore Throat Yes No Fatigue Yes No Chest Tightness/Pressure Yes No Shortness of Breath (Dyspnea) Yes No Runny Nose/ Nasal congestion Yes No Headache Yes No Nausea/Vomiting/ Abdominal pain Yes No Diarrhea /Cramps Yes No Sudden Loss of Smell/Taste Taste disorder Yes No Difficulty swallowing Yes No Atypical Symptoms Malaise/myalgias - Acute functional decline Delirium (acutely altered mental status and inattention) - Croup Unexplained or increased number of falls - Conjunctivitis Exacerbation of chronic conditions OtherOther Patient's Name Patient's Signature and date If you are human, leave this field blank. Submit
