COVID-19 Questionnaire |

COVID-19 Questionnaire

In order to keep our patients and team members safe and healthy at this time, please complete this form at least 4 days prior to your consult. We are committed to keep everyone in our clinic well, and appreciate your assistance!

Full name*

Please answer all of the below that apply to you

Recently travelled overseas*

Yes
No

Had contact with a known or suspected COVID-19 patient in the past 2 weeks*

Yes
No

Reside or visited a known high-risk area with cluster cases*

Yes
No

Undergone a COVID-19 test in the past 2 weeks*

Yes
No

Temperature of 37.5C or higher (temperature tests are done at entry to clinic)*

Yes
No

A cough*

Yes
No

Sore throat*

Yes
No

Shortness of breath*

Yes
No

Respiratory symptoms*

Yes
No

Recent loss of sense of smell*

Yes
No

Thank you for your help!