COVID Screening Form – Skyward Living

Thank you for carefully considering the health and safety of our staff and residents when completing the following:
Name*
First Last
Phone*
Building*
Date of Appointment or Booking*
MM slash DD slash YYYY
Time of Appointment or Booking*

: Hours

Minutes

AM/PM
1. Do you have any new onset (or worsening) of any of the following symptoms:

• Fever*
• Cough*
• Shortness of breath / difficulty breathing*
• Runny nose*
• Sore throat*
• Chills
• Painful swallowing
• Nasal congestion
• Feeling unwell / fatigued
• Nausea / vomiting / diarrhea
• Unexplained loss of appetite
• Loss of sense of taste or smell
• Muscle/ joint aches
• Headache
• Conjunctivitis (commonly known as pink eye)

*Individuals with fever, cough, shortness of breath, runny nose, or sore throat, are required to isolate for 10 days per CMOH Order 05-2020

2. Have you travelled outside Canada in the last 14 days? (Individuals are legally required to quarantine for 14 days when entering or returning to Alberta from outside Canada unless exempted by the Alberta COVID-19 Border Testing Pilot Program.)

3. Have you had close contact with a case of COVID-19 in the last 14 days?
Are the answers to any of these questions yes?*
- Yes
- No
If you can answer YES to any of the questions above, please reschedule your appointment to a date occurring after the required isolation period is complete.

By clicking SUBMIT, you affirm that your answer is NO to all questions noted above.