Home
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