COVID-19 Screen
Please complete within 24h of your appointment in the office.
Do you have any of the following: difficulty swallowing, nausea/vomiting, stomach pain or diarrhea? *
1 point
Have you had a COVID-19 test in the last 14 days? *
1 point
Do you have a new onset or worsening cough, shortness of breath, difficulty breathing or loss of sense of taste or smell? *
1 point
Have you had close contact with anyone with acute respiratory Illness in the last 14 days? *
1 point
Do you have any of the following: fever, chills, headaches, unexplained fatigue or muscle aches? *
1 point
Do you have a confirmed case of COVID-19 or close contact with a confirmed case of COVID-19? *
1 point
Do you have any of the following: sore throat, runny or stuffy nose or pink eye?
1 point
Clear selection
Have you travelled outside of Ontario in the past 14 days or been in close contact with someone who has travelled outside of Ontario? *
1 point
Submit
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