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

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Treating Sleep Apnea and Snoring Since 1994
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Latest News

Obstructive sleep apnea during REM sleep & blood pressure.

Obstructive sleep apnea during REM sleep: effects on morning and evening blood pressure. This new...

March 11th, 2023

Fantastic New Device – SomnoDent Avant

Dr. Halstrom is happy to report that our recent results using the SomnoMed Avant device are simply...

January 13th, 2023

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?

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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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