Name *

First Name

Last Name

Date *

Please complete within 24hrs of your appointment and enter the date of your scheduled appointment.

MM

DD

YYYY

COVID-19 Symptoms *

Have you had any of the following signs or symptoms (without other known cause or chronic condition) in the last 10 days? Fever or chills Cough (either new, or worsening of chronic cough) Sore throat Shortness of breath or difficulty breathing Extreme fatigue or tiredness Loss or change of sense of taste or smell Diarrhea Headache Nausea or vomiting Runny nose Sneezing Body or muscle aches

YES in the last 5 days

YES in the last 10 days

No, none of the above.

Symptoms Date

If you checked YES to any symptoms, when did they begin?

MM

DD

YYYY

Symptoms Status

If you checked YES, are the symptoms improving?

Yes

No

Fever

Have you had a fever in the last 24hrs?

Yes

No

COVID-19 Testing *

Have you tested POSITIVE for COVID-19 in the last 10 days?

YES

No

Date of COVID-19 Positive Result

When was the date of your COVID-19 POSITIVE result?

MM

DD

YYYY

Self-Isolation *

Have you been told to self-isolate by Public Health, a Health Care Professional, or a member of Canada Border Services in the last 5 to 10 days?

Yes, in the last 5 days

Yes, in the last 10 days

No