COVID-19 Screen Questionnaire
All staff or guests must complete before entering the office.
Do you have any of the following new or worsening symptoms or signs?
Fever or chills
Difficulty breathing or shortness of breath
Sore throat or trouble swallowing
Runny or stuffy nose
Decrease or loss of taste or smell
Nausea, vomiting or diarrhea
Not feeling well, extreme tiredness or sore muscles
Pink eye or headache
If you have an existing health condition that gives you the symptoms you should not answer YES, unless the symptom is new, different or getting worse. Look for changes from your normal symptoms.
Does anyone in your household have one or more of the previous symptoms?
Have you been notified as a close contact of someone with COVID-19 or been told to stay home and self-isolate?
In the last 14 days, have you or anyone in your household traveled outside of Canada?
I agree to send this information for COVID-19 screening purposes
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