THE FOLLOWING FORM CAN BE PRINTED OR THERE WILL BE A COPY IN OFFICE FOR YOU TO SIGN ON ARRIVING FOR YOUR VISIT. We ask that you review the following screening questions regarding Covid 19 prior to your visit: Please review the following list and if the answer is yes to any of the questions below, we cannot provide in-person appointments to you, and you are advised to cancel and reschedule your appointment, self isolate and call HealthLink at 811 for further instruction: Please complete this questionnaire prior to your visit. This form will be kept in your file. 1.Are you experiencing any of the following symptoms: Sore Throat/Hoarse Voice◻ YES ◻ NO Headache/Muscle Aches◻ YES ◻ NO Sneezing or Coughing◻ YES ◻ NO Fever or Chills◻ YES ◻ NO Difficulty Breathing/shortness of breath ◻ YES ◻ NO Runny Nose ◻ YES ◻ NO Sinus Congestion ◻ YES ◻ NO Unexplained fatigue/Malaise/Feeling unwell ◻ YES ◻ NO Nausea/Vomiting/Diarrhea ◻ YES ◻ NO Loss of taste/smell◻ YES ◻ NO
2. Have you traveled internationally within the last 14 days (outside Canada) or had close contact with a person who has been outside Canada in the last 14 days? ◻ YES ◻ NO
3. Have you had close contact with a confirmed or probable COVID-19 case? ◻ YES ◻ NO
4. Have you had close contact with a person with acute respiratory illness? YES ◻ NO
5. Are you or anyone living in your household in isolation, quarantine, or awaiting COVID test results?◻ YES ◻ NO I certify that I have answered the questions truthfully. Name:_____________________________________ Signed:____________________________________