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