COVID-19 Screening Form

COVID-19 Screening Form for Long-term Care Homes and Retirement Homes

To protect our residents and team members from the spread of COVID-19, we are conducting modified in-person visit for those interested in moving into Dunbar Heights in the near future. We require every visitor to prescreen and book an appointment prior to visiting.

Note: only visitors who have answered ” No” to all questions are allowed to visit.

A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.

Name

Preferred Contact Number

What day would you like to visit?

What time works best for you?

Who are you inquiring for?

If selected 'Other', please enter the details here

1. Are you currently experiencing one or more of the symptoms below that are new orworsening? Symptoms should not be chronic or related to other known causes orconditions.

Fever and/or chills	Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
Cough or barking cough (croup)	Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have
Shortness of breath	Not related to asthma or other known causes or conditions you already have
Decrease or loss of smell or taste	Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have
(For adults > 18 years or older) Fatigue. lethargy, malaise and/or myalgias	Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have) If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select “No.”
(For children < 18 years) Nausea, vomiting and/or diarrhea	Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have

2. In the last 14 days, have you travelled outside of Canada AND been advised toquarantine per the federal quarantine requirements?

3. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
This can be because of an outbreak or contact tracing.

4. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?

If public health has advised you that you do not need to self-isolate (e.g., you are fully immunized or have tested positive for COVID-19 in the last 90 days and since b een cleared), select “No.”

5. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?

If you are have already gone for a test and got a negative result, select "No."
If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select "No."

6. In the last 10 days, have you tested positive on a rapid antigen test or a homebased self-testing kit?

If you have since tested negative on a lab-based PCR test, select “No.”

7. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.”

If the individual experiencing symptoms received a COVID-19 vaccine in the last 48 hours and is experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No”.

8. In the last 14 days, has someone in your household (someone you live with) travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?

If you are fully immunized or have tested positive for COVID-19 in the last 90 days andsince been cleared, select “No.”

9. In the last 10 days, has someone in your household (someone you live with) been identified as a ”close contact” of someone who currently has COVID-19 AND advised by a doctor, healthcare provider or public health unit to self-isolate?

If you are fully immunized or have tested positive for COVID-19 in the last 90 days andsince been cleared, select “No.”