Covid-19 Pre-visit Screening Questionnaire

    Which location are you visiting today?

    Have you travelled outside of Canada or outside the province within the last 14 days?: NoYes
    Have you been tested positive for Covid-19?
    (please provide neg-test result!!!)
    Have you been identified by Public Health as a close contact of someone with Covid-19?

    Are you required to self-isolate?

    Do you have any of the following symptoms?
    a. Fever or chills:
    b. cough:
    c. Loss of sense of smell or taste:
    d. Difficulty breathing:
    e. Sore throat:
    f. Loss of appetite:
    g. Extreme fatigue or tiredness:
    h. Headaches without other known cause:
    i. Body aches:
    j. Nausea or vomitting:
    k. Diarrhea:
    l. Flu or cold-like symptoms:

    DATE: