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

    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

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