Winnipeg:
(204) 663-9750
Steinbach:
(204) 346-0614
Concord Surgical:
(204) 668-3311
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Steinbach Location
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Concord Surgical
COVID-19 Patient Screening
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Please answer the following questions to ensure you are COVID-19 symptom free.
Patient Name
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Date
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It is important to closely monitor your health and the health of those you care for to help prevent the spread of COVID-19 and other illnesses like the flu.
1. Do You Feel Sick?
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Yes
No
2. In the past 48 hours, have you had, or are you currently experiencing;
Cough (New or Worsening)
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Yes
No
OR two or more of the following symptoms (new or worsening);
Fever (i.e. chills/sweats)
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Yes
No
Sore Throat
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Yes
No
Runny nose/nasal congestion
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Yes
No
Headache
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Yes
No
If yes, go home or stay home as noted above. Follow Public Health instructions for testing and isolation.
3. Have you recently visited a COVID-19 exposure site?
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No
4. Have you travelled in the past 14 days outside of the province and/or country AND been advised to self-isolate?
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