Covid-19 Pre-visit Screening Questionnaire Which location are you visiting today? ---KitsilanoDowntown Have you travelled outside of Canada or outside the province within the last 14 days?: NoYes Have you been tested positive for Covid-19? NoYes (please provide neg-test result!!!) Have you been identified by Public Health as a close contact of someone with Covid-19? NoYes Are you required to self-isolate?NoYes Do you have any of the following symptoms? a. Fever or chills: NoYes b. cough: NoYes c. Loss of sense of smell or taste: NoYes d. Difficulty breathing: NoYes e. Sore throat: NoYes f. Loss of appetite: NoYes g. Extreme fatigue or tiredness: NoYes h. Headaches without other known cause: NoYes i. Body aches: NoYes j. Nausea or vomitting: NoYes k. Diarrhea: NoYes l. Flu or cold-like symptoms: NoYes DATE: