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COVID-19 SCREENING IS MANDATORY FOR ALL ENTERING THE HOSPITAL LEARN MORE

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Patients & Visitors
Hospital Services
- Our Services
  - widget
    At the Middlesex Hospital Alliance, our goal is to provide the healthcare we would expect for our own families. Please select one of our Hospital services for more information.
    
    View All Services
- Services
- Services Continued
Careers & Volunteering
About MHA

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Self Screening Assessment

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Self Screening Assessment

COVID-19 Perimeter Screening for Staff/Physicians

This Self Screening tool is for use by Employees and Physicians Only. All patients and visitors must go through in-person screening at the designated entrances of the hospital. Exit and close browser upon completion of the screening when using a mobile device.

1Name & Department

2Covid Vaccination Confirmation

3Symptoms

4Travel/Contact

Name*
First Last
Hidden
Home Department
What Department are you Working in Today?*
What Site are you Working at Today?*

Hidden
Have you received two doses of Covid vaccine?
- Yes
- No
- Decline to answer
Hidden
Have you received your second dose more than 14 days ago?
- Yes
- No
Hidden
Have you completed your rapid antigen test?
- Negative result
- Positive Result
- Not tested

Are you experiencing any of the following symptoms?*
- Yes
- No
1. Fever or chills
2. New or worsening cough (not related to asthma, post-infectious airways or other known cause)
3. Shortness of breath (not related to asthma or other known condition)
4. Decrease or loss of smell or taste (not related to allergies or neurological disorders or other known cause)
5. Fatigue, lethargy or malaise (unusual tiredness not related to depression, insomnia, thyroid dysfunction or other known cause)
6. Muscle aches and pain (not related to covid vaccine in the last 48 hours or other known conditions)
7. Sore throat or difficulty swallowing
8. Nasal congestion or runny nose
9. Headaches (new, more frequent, unusual or unexplained)
10. Nausea, vomiting or diarrhea

Have you had a positive COVID-19 test within the past 10 days?*
- Yes
- No
Have you had close contact (without the use of personal protective equipment) with a confirmed or probable case of COVID-19 in the past 10 days?*
- Yes
- No
Have you completed a 10 day isolation period after testing positive for COVID-19 in the last 90 days (using a rapid antigen, rapid molecular or PCR test)
- Yes
- No
Hidden
Have you travelled outside of Canada in the past 14 days?
- Yes
- No
Hidden
Has it been more than 14 days since your second dose?
- Yes
- No
Hidden
Have you had a covid test since your return to Canada?
- Yes
- No
Hidden
Have you received your 2nd dose more than 14 days ago?
- Yes
- No
Hidden
Has it been more than 14 days since your second dose?
- Yes
- No
Comments
This field is for validation purposes and should be left unchanged.

Strathroy Middlesex General Hospital

395 Carrie Street,
Strathroy, ON
N7G 3J4
(519) 245-1550

Four Counties Health Services

1824 Concession Drive,
Newbury, ON
N0L 1Z0
(519) 693-4441

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