Screening Form – Union Hearing Aid Centre

COVID Pre Appointment Screening Questionnaire

Please answer the following questions prior to arriving for your appointment.

Name

First Last

1. Do you have a fever?*

Yes
No

2. Do you have any of the following new or worsening symptoms or signs?

Symptoms should not be chronic or related to other known causes or conditions.

Chills
Difficulty breathing or shortness of breath
Cough
Sore throat, trouble swallowing
Runny nose/stuffy nose or nasal congestion
Decrease or loss of smell or taste
Nausea, vomiting, diarrhea, abdominal pain
Not feeling well, extreme tiredness, sore muscles

3. Have you travelled outside of Canada or have had close contact with anyone who has travelled outside of Canada in the past 14 days?*

Yes
No

Note:
If you have answered "yes" to any of the above, you will need to reschedule your appointment. Please contact receptions at 416-364-2264

4. Have you tested positive for COVID-19?*

Yes
No

5. Do you have a pending test result for COVID-19?*

Yes
No

If yes, please provide additional information and contact reception at 416-364-2264.*

6. Have you had close contact with anyone with respiratory illness or a confirmed or probable/suspected case of COVID-19, without wearing the appropriate PPE?*

Yes
No

If your answer is yes, please provide additional information and contact reception at 416-364-2264*

COVID Pre Appointment Screening Questionnaire

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