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COVID-19 ASSESSMENT
- COVID Connect Self Assessment
- COVID Nursing/ Physician Assessment

Home
Connected Care
Our Market
About Us
News & Blogs
Contact Us
COVID-19 ASSESSMENT
- COVID Connect Self Assessment
- COVID Nursing/ Physician Assessment

Home
Connected Care
Our Market
About Us
News & Blogs
Contact Us
COVID-19 ASSESSMENT
- COVID Connect Self Assessment
- COVID Nursing/ Physician Assessment

Home
Connected Care
Our Market
About Us
News & Blogs
Contact Us
COVID-19 ASSESSMENT
- COVID Connect Self Assessment
- COVID Nursing/ Physician Assessment

COVID Nursing/ Physician Assessment

Symptom History

Onset of not feeling well

Do you have a cough

Yes No

Do you have a fever greater than 38 degrees

Yes No

Do you have trouble breathing

Yes No

Do you have a runny nose

Yes No

Do you have a sore throat

Yes No

Do you have any discharge from your eyes

Yes No

Do you have any abdominal symptoms like nausea, vomiting or diarrhea

Yes No

Are you feeling severe fatigue or extreme muscle aches

Yes No

Have you travelled in the last 14 days

Yes No

Travel Details (If Yes)

Have you been in close contact with someone diagnosed with COVID 19

Yes No

Contact With Someone (If Yes)

High Risk Factors

Have you recently been hospitalized ?

Yes No

If Yes

Have you recently had surgery ?

Yes No

If Yes

Have you recently had treatment for cancer ?

Yes No

If Yes

Are you on any medications that lower your immune system ?

Yes No

Medical History (If Yes)

Medication List (If Yes)

Allergies to Medications (If Yes)

Have you been diagnosed with Diabetes?

Yes No

If Yes

Have you been diagnosed with Heart Disease?

Yes No

If Yes

Social History

Where do you live ?

What type of work do you do ?

Are there any family members in your home that are over 70 ?

Yes No

Current Vitals

Are you able to provide any of your vitals at home ?

Assessment and Plan

For Clinical Use Only

Mild Symptoms: Low risk of COVID, self isolate x 14 days, if symptom free for 48 hours can return to normal activities while practicing social distancing , supportive treatment of symptoms. Moderate Symptoms: Possible risk of COVID , self isolate 14 days, referral to testing centre follow infection control guidelines for patient transport. Severe Symptoms: Call 911 or have patient go to nearest emergency department, notify EMS or hospital immediately.

CPR Status, If known

Ministry Form Completes

Yes No

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