Covid-19 Pre-visit Screening Questionnaire

    Which location are you visiting today?

    Have you, or anyone in your household travelled outside of Canada within the last 14 days?: NoYes
    Have you been tested positive, or show any symptoms of Covid-19 within the last 14 days?
    Are you currently waiting for test results for Covid-19?
    Have you been identified by Public Health as a close contact of someone with Covid-19?
    Are you required to self-isolate?

    DATE: