Fraser Northwest Division Influenza-Like Illness and COVID-19 Assessment Centre 107 - 301 E Columbia Street, New Westminster Email: assessmentclinicphysician@fnwdivision.ca Fax: 844-910-1874 Clinic Hours: M-F 9AM-8PM, Sa-Su 9AM-5PM *Patients will receive a phone call for an appointment within an hour upon receipt of this form.

Patient name: Patient age: PHN: DOB: (dd/mm/yyyy) Patient Phone: Patient Cell:

SAFETY Patient wearing mask

SYMPTOMS Fever (may be low grade) Cough Fatigue Shortness of breath Sore throat Headache Myalgias / Arthralgias GI symptoms Other symptoms: Patient requires in-home assessment: YES NO

CRITERIA for COVID testing: Health Care Worker (incl pharmacists) First Responders LTC facility resident and staff Patient likely to be hospitalized Cancer/Dialysis patient Pregnant, >28 weeks Pending essential surgery Investigation of Cluster or Outbreak Resident of isolated/remote/indigenous community Homeless or unstable housing Returning traveller identifed at point of entry to Canada Must QUARANTINE 14 days and self-monitor. Clinical judgement/testing will change management Unsure/Other per latest MHO Guidelines ▲ ▼ MD RESOURCES BC COVID Self-Assessment FNW COVID Self-Assessment MD Reference

PATIENT RESOURCES (Ctrl-P to print) If you are sick... How to self-isolate (no symptoms) How to self-isolate (WITH symptoms) Guide for close contacts How to self-monitor

Reason to be seen/assessed by physician: ▲ ▼

* * SEND PATIENT TO EMERGENCY ROOM IF THEY HAVE SEVERE SHORTNESS OF BREATH AND/OR CHEST PAIN. * * NOT EVERYONE NEEDS A SWAB.  Please ensure you have reviewed the most recent Guidelines, available at the BC CDC: http://www.bccdc.ca/Health-Professionals/clinical-resources/covid-19-care/lab-testing.