For ALL IN-CLINIC Patients, It is required to fill out this screening questionnaire for EACH VISIT to the clinic

Please Carefully read and answer ALL following questions:

1 – Have you, or anyone in your house, travelled internationally or out of province within the past 2 weeks?
YesNo

2- Have you been in contact with anyone in the past 2 weeks that has tested positive for COVID-19?
YesNo

3- Do you currently have ANY of the following symptoms? Fever of 38C / 100.4F or higher?
YesNo

New Onset or worsening of chronic Cough?
YesNo

Shortness of Breath?
YesNo

Sore Throat?
YesNo

Runny Nose?
YesNo

Flu Like Symptoms (Fatigue, Joint Pain, Muscle Ache)?
YesNo

4- Does anyone living in your household have ANY of the above symptoms?
YesNo

5- Have you or anyone in your house tested positive for COVID-19?
YesNo

If you answer “YES” to any of above question, we ask that you immediately contact the clinic at 905-237-7174 to discuss appropriate next steps and in-person appointments alternatives.

Declaration:

I have answered all the above questions honestly and truthfully

Signature