Health Questionnaire

Patient's Name *

First Name

Last Name

Responsible Party *

First Name

Last Name

Phone Number *

(###)

###

####

Date of Patient's Appointment *

MM

DD

YYYY

Do you have a fever, or have you had a fever in the last 14 days? *

Yes

No

Do you have shortness of breath or other difficulties breathing? *

Yes

No

Do you currently have a cough? *

Yes

No

Do you have other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue? *

Yes

No

Have you experienced loss of taste or smell recently? *

Yes

No

Have you travelled outside of Canada in the past 14 days? *

Yes

No

If YES, have you followed all Government guidelines for re-entry, including a negative PCR test when necessary?

Yes

No

N/A

Have you had close contact with anyone that is confirmed COVID-19 positive within the last 14 days? *

Yes

No

Have you had a positive COVID-19 test result? *

Yes

No

If YES, have you isolated for the required period as per Public Health and/or been medically cleared?

Yes

Not yet

N/A