Name *

First Name

Last Name

Do you have a fever or above-normal temperature? *

Yes

No

Have you experienced shortness of breath or had trouble breathing? *

Yes

No

Do you have a dry cough? *

Yes

No

Do you have a runny nose? *

Yes

No

Have you recently lost or had a reduction in your sense of smell? *

Yes

No

Do you have a sore throat? *

Yes

No

Have you been in contact with someone who has tested positive for COVID-19? *

Yes

No

Have you tested positive or negative for COVID-19? *

Yes

No

Have you been tested for COVID-19 and are awaiting results? *

Yes

No

Have you traveled outside Canada by air or cruise ship in the past 14 days? *

Yes

No

Have you traveled within Canada, by air, bus or train within the past 14 days? *

Yes

No

Do you have a weakened immune system? *

Yes

No

Are you currently undergoing treatment for cancer, such as chemotherapy or radiation therapy? *

Yes

No

Do you take steroids for any conditions? *

Examples of common steroids are Cortisone, Prednisone, Methylprednisone. Contact your physician or our office if not sure. Answer YES if unsure.

Yes

No

Do you have an autoimmune disease such as Lupus, rheumatoid arthritis, multiple sclerosis or psoriasis? *

Yes

No

Do you have diabetes? *

Yes

No

If so, do you have or take insulin injections? *

Yes

No

Do you have asthma or COPD? *

Yes

No