PLEASE DO NOT ENTER THE CLINIC

WITHOUT COMPLETING THE QUESTIONNAIRE or IF YOU ANSWERED YES TO ANY OF THE QUESTIONS

1. Do you have any of the following symptoms: Fever/Feverish, chills, new or worsening cough, sore throat, shortness of breath, unexplained fatigue/malaise/muscle aches, or runny nose/nasal congestion without other known cause?

 YES  NO

Close physical contact
– being less than 2 meters away in the same room, workspace or area for more than 15 minutes.
– Living in the same house

2. Have you come in close contact with someone who is presenting with the above symptoms?

 YES  NO

3. Have you had close physical contact within the last 14 days with a confirmed or suspected case of COVID-19?

 YES  NO

4. Have you returned from travel outside of Canada or been in close physical contact with someone who has within the last 14 days?

 YES  NO