COVID-19 QUESTIONNAIRE Home 5 COVID-19 QuestionnaireCOVID-19 QuestionnaireIn 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 youRecently travelled overseas* Yes NoHad contact with a known or suspected COVID-19 patient in the past 2 weeks* Yes NoReside or visited a known high-risk area with cluster cases* Yes NoUndergone a COVID-19 test in the past 2 weeks* Yes NoTemperature of 37.5C or higher (temperature tests are done at entry to clinic)* Yes NoA cough* Yes NoSore throat* Yes NoShortness of breath* Yes NoRespiratory symptoms* Yes NoRecent loss of sense of smell* Yes NoThank you for your help!
