Covid Screening Questionnaire Covid Screening Screening Questionnaire for Covid-19 Symptoms that must be filled out before each appointment. Name* First Last Phone*Email* Do you have a fever, new onset of cough, worsening chronic cough, shortness of breath, or decrease or loss of sense of smell or taste? ?* Yes No Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?* Yes No Are you vaccinated?* Yes No Did you receive your second vaccine dose more than 14 days ago?* Yes No Have you travelled outside of Canada in the past 14 days?* Yes No Have you had any close contact to someone with a confirmed case of COVID-19 without wearing appropriate PPE?* Yes No Consent* I agree that this information is accurate and true.EmailThis field is for validation purposes and should be left unchanged.
