Dr. Halstrom | Pre-Appointment Screening - Dr. Halstrom

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Dr. Halstrom & The Silencer – Successfully Treating Sleep Apnea and Snoring Since 1994
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INSURANCE COVERAGE

The Silencer is covered by many extended health insurance plans, among them Pacific Blue Cross...

February 8th, 2020

NEW – Book your telephone consultation Online!

BOOK NOW We are pleased to offer you the opportunity to directly book a 15-30 minute telephone...

December 12th, 2019

Pre-Appointment Screening

COVID-19 SCREENING

Name
First Last
Date of Birth:
In the past 14 days have you had any history of fever?*
- Yes
- No
In the past 14 days have you had any new onset of cough or difficulty in breathing?*
- Yes
- No
Have you or any household members traveled outside of Canada in the past 14 days?*
- Yes
- No
Have you or any household members had close contact with a confirmed or probable case of COVID-19?*
- Yes
- No
Have you been tested for COVID-19 in the last 14 days?*
- Yes
- No
If yes to testing - indicate status:
- Unknown
- Negative
- Positive
Are you diabetic or have an auto-immune disease like lupus rheumatoid arthitis,celiac disease, etc?*
- Yes
- No
Any other medical conditions we should be aware of?*
- Yes
- No
Cell Phone Number For Day Of Appointment?
On the day of the appointment we will ask you to wait nearby or in your vehicle - we will call you to the office once we have finished with the previous patient.

About Dr. Halstrom

With a great deal of good fortune I was able to walk away from a serious single car accident. Following the accident I was diagnosed with sleep apnea. I tried CPAP therapy unsuccessfully, as I was unable to accommodate to the daily requirements of wearing the mask....Read More

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