COVID-19 and Related Form Updates

The screening forms have been updated to match the most recent screening questions in the Ontario screening form:

• The COVID vaccination question has been removed.
• The travel screening question has been removed.
• The quarantine question has been updated to, "Have you been told that you should currently be quarantining, isolating or staying at home?"
• The testing question has been updated to, "In the last 10 days, have you tested positive for COVID‐19? (with either a home/rapid test kit or a PCR test)"

The updated forms include:

• COVID-19 Email Screening Form
• COVID-19 Website Triaging Form
• COVID-19 Kiosk Screening Form
• COVID-19 Online Booking Screening Form

If you have any concerns, please reach out to our support team to let us know.

The screening forms have been updated to again include sore throat, runny nose and congestion as screening symptoms. These symptoms were originally removed in the provincial screening tools prior to the Omicron wave but have since been restored.

The updated forms include:

• COVID-19 Email Screening Form
• COVID-19 Website Triaging Form
• COVID-19 Kiosk Screening Form
• COVID-19 Online Booking Screening Form

If you have any concerns, please reach out to our support team to let us know.

The screening forms have been updated to screen positive regardless of vaccination status in the event of a "close contact" COVID exposure. In addition, the "Have you been fully vaccinated?" question has been changed to, "Have you had at least two doses of COVID-19?" for clarity in this context.

The updated forms include:

• COVID-19 Email Screening Form
• COVID-19 Website Triaging Form
• COVID-19 Kiosk Screening Form
• COVID-19 Online Booking Screening Form

If you have any concerns, please reach out to our support team to let us know.

Due to the recent travel concerns related to Omicron, the travel question has been reinstated regardless of vaccine status. Furthermore, due to the fast-changing nature of the quarantine restrictions, the travel question has been split into three separate questions:

• In the last 14 days, have you travelled outside of Canada?
  • Where did you travel?
  • Are you currently under federal quarantine restrictions or have you been advised to be in isolation?

Answering "YES" to the second question will result in a positive screen, advising patients to avoid attending the clinic in-person. Otherwise, the patient's answer is merely flagged as red.

The updated forms include:

• COVID-19 Email Screening Form
• COVID-19 Website Triaging Form
• COVID-19 Kiosk Screening Form
• COVID-19 Online Booking Screening Form

If you have any concerns, please reach out to our support team to let us know.

The screening questions have been updated to align the tool with the latest wording in the Ontario screening form. Also in alignment with the Ontario screening form: Patients who claim full vaccination will no longer screen positive when they answer "Yes" to any exposure risk questions. As before, the patients will screen positive when they have any of the listed symptoms, regardless of vaccination status.

The updated forms include:

• COVID-19 Email Screening Form
• COVID-19 Website Triaging Form
• COVID-19 Kiosk Screening Form
• COVID-19 Online Booking Screening Form

If you have any concerns, please reach out to our support team to let us know.

A minor change to the travel question has been released to align the tool with the latest wording in the Ontario screening form.

• The travel question has been updated from this:
  • In the last 14 days, have you travelled outside of Canada and been told to quarantine (per the federal quarantine requirements)?
• ... to the following:
  • In the last 14 days, have you travelled outside of Canada?
    • If exempt from federal quarantine requirements (for example, you are fully vaccinated and have met the specific conditions, or an essential worker who crosses the Canada-US border regularly for work), select "No."

The updated forms include:

• COVID-19 Email Screening Form
• COVID-19 Website Triaging Form
• COVID-19 Kiosk Screening Form
• COVID-19 Online Booking Screening Form

If you have any concerns, please reach out to our support team to let us know.

A few modifications to the under-18 questions have been made to align the questions with the Ontario provincial screening form:

• The Muscle aches/joint pain and Extreme Tiredness questions have been removed for patients under age 18
• The "Nausea, vomiting, and/or diarrhea" question has been added for patients under age 18

The updated forms include:

• COVID-19 Email Screening Form
• COVID-19 Website Triaging Form
• COVID-19 Kiosk Screening Form
• COVID-19 Online Booking Screening Form

If you have any concerns, please reach out to our support team to let us know.

A few questions have been edited or removed to mirror the Ontario provincial screening form in accordance with the new Aug 26, 2021 Ontario provincial screening guidelines:

• A number of questions associated with poor specificity (high false positive rates) have been removed: sore throat, difficulty swallowing, nasal congestion, pink eye, headache, gastrointestinal symptoms, falling down often
• The "close contact" and "COVID alert" isolation period has been shortened from 14 days to 10 days
• Minor formatting improvements were made to italicize the contextual explanations in the symptom page.

The updated forms include:

• COVID-19 Email Screening Form
• COVID-19 Website Triaging Form
• COVID-19 Kiosk Screening Form

If you have any concerns, please reach out to our support team to let us know.

As a small follow-up to the Aug 4, 2021 update, based on our client requests to mirror the Ontario provincial screening form:

• A initial question has been added, "Are you fully vaccinated against COVID-19? Fully vaccinated means it has been 14 days or more since your final dose of either a two-dose or a one-dose vaccine series.". This question will help guide the follow-up plan for positive screening and informs the clinic regarding patient vaccination status.

The updated forms include:

• COVID-19 Email Screening Form
• COVID-19 Website Triaging Form
• COVID-19 Kiosk Screening Form

If you have any concerns, please reach out to our support team to let us know.

This is a major update to CognisantMD's core screening forms for COVID-19. Most significantly, the new screening questionnaire de-emphasizes travel exposures and accounts for vaccination status. In accordance with recent guidelines, especially with the delta variant in mind, the questionnaire continues to consider symptoms and direct exposures to COVID-19 a positive screen, although it also accounts for specific exemptions when appropriate.

Most of the screening tools available online at the time of this posting have not been updated to account for vaccination status and these other considerations. However, Ontario has recently released a new version:
https://covid-19.ontario.ca/screening/customer/symptoms

In the absence of other guidance, the CognisantMD questionnaire has been updated to reflect the questions included in this Ontario open-source tool. Fortunately, the questions in this new form are generally applicable in any province, not just Ontario.

The updated forms include:

• COVID-19 Email Screening Form
• COVID-19 Website Triaging Form
• COVID-19 Kiosk Screening Form

If you have any concerns, please reach out to our support team to let us know.

The COVID screening forms have been updated to include an additional warning as shown in the Ontario assessment tool:

"Everyone in your household must stay home if anyone has COVID-19 symptoms or is waiting for test results after experiencing symptoms. Unless you have been instructed otherwise, stay home until the person with symptoms gets a negative COVID-19 test result, or is cleared by public health, or is diagnosed with another illness."

• Updated the exposure section to clarify that the symptoms or events have occurred "Within the past 14 days..."
• Updated the potential-exposure question to the following wording: "Have you tested positive for COVID-19 or have you had close contact with a confirmed case of COVID-19?"

• Added "Have you tested positive for COVID-19?" as an extra question in accordance with the Ontario guideline document
• Updated the exposure question to the following: "Have you had close contact with someone who is sick with new respiratory symptoms or who has tested positive for COVID-19? (without wearing appropriate personal protective equipment)"

• In reference to the updated Jun 11, 2020 update to the Ontario guidelines:
• http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_patient_screening_guidance.pdf
• The exposure section has the clarification statement "(without wearing personal protective equipment)" added when appropriate.
• Note that the travel question has been intentionally kept in our forms to screen for "out of the province" rather than "out of the country" due to the provincial discrepancies in COVID-19 rates and the general risks associated with interprovincial travel.

• The forms have been updated based on various sources including Ontario's May 28, 2020 provincial testing guidelines
• The clinical note has been condensed to reduce chart clutter, which is particularly useful for the email screening form, the kiosk screening form, and the online booking screening form. The note headings have been removed and "No" questions have been combined into single statements for each section ("No travel or potential exposures reported.", "No covid-related symptoms.")
• A note summary is now included for positive screens to document the advice given to the patient in the form itself ("Advised to contact healthcare provider, consider testing, wear a mask, use contact precautions, and self-isolate.")
• The email screen and triaging forms are now compatible with Ocean's email notification "red flag" feature, such that completion notification emails will include " - RED" in the subject and "The note has been flagged as red." in the email notification body. This feature allows clinics to set up workflows to follow up in a more timely manner for positive screens.

In accordance with the May 14, 2020 provincial guidelines, "As of May 14, 2020, any Ontarian presenting with at least one symptom or sign from the list below should be considered for testing for COVID-19":

http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/2019_guidance.aspx#case)

The COVID screening algorithm has been updated accordingly:

• Any major or minor symptom on its own is now considered sufficient for a positive screen and a testing consideration (previously 2 "minor" symptoms were required)
• Hoarseness and sneezing have been removed as symptoms
• Changed the testing recommendation text from, "You are probably eligible for COVID-19 testing" to the more informative, "Based on Canadian guidelines, COVID-19 testing should be considered."

• The ER symptoms are now asked up-front, prior to the general symptom screen, which is in alignment with the majority of other screening and assessment tools.
• Most of the separate yes/no questions have been converted to a checkbox/"none of the above" approach to make it much less tedious for patients to complete each time.
• With the expansion of testing to all exposed and symptomatic individuals, the algorithm is somewhat simpler. The vulnerable-population and occupational questions are no longer needed for the recommendations, so they have been removed. The outcome for the screening protocol has been simplified to 3 outcomes: ER redirection, positive screen with testing suggested, and a negative screen. The messaging has been updated in accordance with the clinical guidelines for each scenario.
• The symptom checklist has been updated to incorporate the best wording and elements from the Ontario May 2 guidelines, in addition to the Ontario provincial tool, the covid19Toronto tool, and others.
• The French translations have been updated for the email screening questionnaire, the triaging tool, and the self-assessment tool. (If any further edits are required for the French translations of these tools, please reach out to info@cognisantmd.com)

• Updated the symptom screening algorithm to reflect the Ontario Ministry of Health COVID-19 Screening Guidance Document (current May 2, 2020) 
  • In particular, the symptom list is now:
    • fever
    • new or worsening cough
    • shortness of breath at rest, or an inability to lie down because of difficulty breathing
    • sore throat
    • hoarse voice
    • difficulty swallowing
    • lost sense of taste or smell
    • chills
    • headaches
    • unexplained fatigue / illness-feeling
    • diarrhea
    • abdominal/stomach pain
    • nausea / vomiting
    • pink eye (conjunctivitis)
    • runny nose/sneezing without other known cause
    • nasal congestion without other known cause
  • The following new questions will also show for patients over age 65:
    - delirium (sudden confusion or unpredictable emotional distress)
    - unexplained or increased number of falls
    - sudden unexplained decline in ability to function with routine daily activities
    - unexplained worsening of chronic illness

• Updated the home and occupational risk factors to a new "Workplace and Home Setting" section to account for the latest Ontario testing criteria:
• Added specific mentions for: caregivers, personal support workers, group homes, nursing homes, rural, remote, isolated or Indigenous community, and other essential service providers
• Changed the "Workplace and Home Setting" section to use a checkbox and "none of the above" to reduce the number of "no" clicks for typical submissions
• Changed "immunosuppression" to "a condition or treatment that affects your immune system (e.g. HIV, lupus, other autoimmune disorder)
• Changed "cardiovascular disease (including heart attack)" to "heart condition / cardiovascular disease"
• For the self assessment tool and the triaging form, changed the wording for patients when testing is likely indicated. Previously it did not specifically mention that COVID-19 testing may be indicated due to the policy of test rationing. Now with clear guidelines, in accordnace with the Ontario tool, it says: "Please call your healthcare provider or your local telehealth provider. You may be eligible for a COVID-19 test. You should self-isolate in the meantime. Do not leave your home until you are instructed to do so."
• Improved some of the French translations

All Tools:

• Updated the initial symptom screening list to limit the number of "false positive" new symptoms (changed questions are marked with a *). Added sudden complete loss of smell or taste (anosmia / dysgeusia) as an important new presenting symptom.
  • fever
    chills or shakes
    sore throat
    cough
    headache
    new unexplained muscle aches *
    new or worsening fatigue *
    runny nose
    new widespread joint aches *
    nausea
    diarrhea
    abdominal/stomach pain
    shortness of breath at rest, or an inability to lie down because of difficulty breathing
    sudden complete loss of smell or taste *
• Updated French translations
• Changed all positive symptom answers to flag in red
• Changed all positive occupational / risk answers to flag in yellow or red
• Added a new red stop sign image for emergency department redirects
• Added pregnancy as a risk factor question

Kiosk Screen

• Updated and expanded the kiosk and online booking screening questions for consistency with the other tools

Self Assessment Tool

• Moved the Age question into a separate preliminary page

• In accordance with other symptom checkers, we have updated the emergency questions to limit the number of patients unnecessarily sent to the ER:
  • Dropped the dizziness question since it is no longer listed in other tools
  • Changed "chest pain" to "severe chest pain"
  • Changed to "severe difficulty breathing (for example, struggling for each breath, speaking in single words)"
• Updated the French version of the tool with similar translations

• Updated the tool to reflect the latest guidelines in Toronto as well as the general recommendations in the Alberta, BC and Ontario tools. Please note that there is not a universal consensus in terms of how the questions should be asked or even what the recommendation should be in terms of testing.  However, we have updated the tool to reflect the key recommendations shared across all the tools, while also collecting and documenting a useful history for clinicians.
• Updated the previous indication for COVID-19 testing (symptoms + (occupational exposure or age/comorbidity) to advise the patient to instead call for advice. The guidelines for this decision aren't yet universally accepted in the country. The current recommendation among the Toronto hospitals is to keep these patients isolated at home rather than sending them in for testing, due to the risk of contracting or spreading the virus.
• Updated the symptom-but-no-risk message to be clearer regarding the advice against testing: "Since you have symptoms, it is possible that you have the COVID-19 virus. However, testing is currently not recommended due to the risk of exposing yourself or others the virus."
  The guidelines suggest it is better for these patients to self-isolate at home.
• Changed the lethargy question to: "having a very hard time waking up or feeling confused with decreased consciousness", since many patients do not know what "lethargy" means. (Consistent with the Toronto symptom checker.)
• Changed the weakness question to say "severe", i.e. "severe weakness that impairs your ability to carry out activities of daily living (such as showering, preparing meals, and dressing)" - to limit false positives sending patients to the ER.

 References:

• https://covid-19.ontario.ca/self-assessment
• https://myhealth.alberta.ca/Health/pages/symptom-checker.aspx
• https://covid19toronto.ca/
• Attached below is an assessment algorithm for Toronto Public Health from Mar 16. Please note that its recommendation 3) for testing does not reflect the symptom checkers' recommendations because it is designed for individuals who have already presented to an assessment centre. According to ID specialists at the Toronto hospitals, for individuals still at home, the risk of going in for testing is believed to outweigh the benefit and will quickly exhaust the testing and PPE supply.
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