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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Latest News

New “Super Silencer” – Mandibular Repositioning Device for Obstructive Sleep Apnea

The “Super Silencer” is a specialty device recently developed with Mr. Loris Campagnolo...

May 6th, 2022

Treatment Options In Obstructive Sleep Apnea

Treatment Options In Obstructive Sleep Apnea Gambino, F., Zammuto, M.M., Virzì, A. et al....

April 26th, 2022

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 - difficulty in breathing or loss of sense of smell or taste?*
- Yes
- No
Are you currently experiencing any of the following new or worsening symptoms of COVID-19 for more than 24 hours?*
- None of the below symptoms.
- Sore throat?
- Extreme fatigue or tiredness?
- Body aches?
- Diarrhea?
- Loss of appetite?
- Headache?
- Nausea or vomiting?
Are you or any household member under order to quarantine after travel outside of Canada?*
- Yes
- No
In the past 14 days have you or any household members had close contact with a confirmed or probable case of COVID-19?*
- Yes
- No
Have you been tested or recommended for a COVID-19 test 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.

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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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