Health Canada screening questionnaire: Date Effective: October 17th, 2022

Please answer the following questions.

Please Note: You would be asked the same questions upon arrival to the office. If there are any changes after you send the screening form, please call our office asap to reschedule the appointment.



    Factors such as old age, diabetes and end-stage renal disease are generally not considered immunocompromised. Examples of being immunocompromised include: individuals undergoing cancer chemotherapy, individuals with untreated HIV infection with CD4 T lymphocyte count less than 200, individuals with a combined primary immunodeficiency disorder, individuals on prednisone medicatIon - more than 20 mg per day (or equivalent) for more than 14 days or on other immune suppressive medications.














    (Select "NO to all symptoms" if all of these apply:
    * you have completed your isolation period or you tested negative for COVID-19 on one PCR test or rapid molecular test or two rapid antigen tests taken 24 to 48 hours apart and
    *you do not have a fever and
    *your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting and/or diarrhea?)