COVID-19 Screening – Glen Erin Animal Hospital

Visitor Name*

First Last

Visitor Contact Number*

Pets name?*

1. 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:

Fever or chills*

Yes
No

Difficulty breathing or shortness of breath*

Yes
No

Cough*

Yes
No

Sore throat, trouble swallowing*

Yes
No

Runny nose/stuffy nose or nasal congestion*

Yes
No

Decrease or loss of smell or taste*

Yes
No

Nausea, vomiting, diarrhea, abdominal pain*

Yes
No

Not feeling well, extreme tiredness, sore muscles*

Yes
No

2. Have you travelled outside of Canada in the past 14 days?*

Yes
No

3. Have you had close contact with a confirmed or probable case of COVID-19?*

Yes
No

Signature*

Date

Results of Screening Questions:

If the individual answers NO to all questions, they have passed and can enter the workplace.
If the individual answers YES to any question, they have not passed and should be advised that they should not enter the workplace (including any outdoor, or partially outdoor workplaces). They should go home to self-isolate and contact their health care provider or Telehealth Ontario (1-866-797-0000) to find out if they need a COVID-19 test.