Covid-19 | MKSCHAIR

Covid-19 Health Questionnaire

How are you feeling today?

Full Name

Phone #

* PLEASE NOTE THAT IF YOU HAVE ANY OF THE FOLLOWING SYMPTOMS YOU WILL BE ASKED TO RESCHEDULE *

Do you have any of the following symptoms?

Fever and/or Chills

Cough

Shortness of breath

Decrese or loss of smell or taste

Sore throat

Difficulty swallowing

Pink eye

Runny or stuffy nose

Headache

Nausea, Vomiting, Diarrhea, Stomach Pain

Muscle aches

Extreme tiredness

Falling down often

NONE OF THE ABOVE

I have not travelled outside of Canada in the last 14 days.

I have not been in close contact with a positive COVID-19 case in the last 14 days.

I have not been told by a health care provider, or public health unit to stay at home or in isolation.

613 803-3038