COVID Prescreening Form - FMC
If you answer yes to any questions, please do not enter - contact your health care provider or telehealth Ontario
Your name
Do you have new or worsening fever symptoms or chills?
Do you have new or worsening difficulty in breathing or shortness of breath?
Do you have a new or worsening cough?
Do you have a new or worsening sore throat or trouble swallowing?
Do you have a new or worsening case of runny nose/stuffed nose or nasal congestion?
Do you have a new or worse case of loss of a sense of taste or smell?
Do you have a new or worsening case of nausea, vomiting, diarrhea or abdominal pain?
Do you have a new or worsening case of extreme tiredness or sore muscles?
Have you travelled outside of Canada in the last 14 days?
Have you had close contact with a confirmed case of COVID 19 in the last 14 days?
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