COVID Questionnaire for In-Person Appointment

When is your in-person appointment?*

Today
Tomorrow
In 2 days

I will be accompanying a patient for his/her appointment. Enter Name of Patient, if applicable:

Are you experiencing any of the following symptoms? Check all that apply:*

Fever
New or worsening cough; or shortness of breath
Sore throat, nasal congestion, sneezing
New loss of smell or taste
New or worsening headache, body aches, chills, rash, nausea or vomiting, diarrhea
None of the above

Have you had a COVID test in the last 14 days?*

Yes- it was Negative
Yes- it was Positive
Yes- I am still waiting for results
No- I did not have a recent test

Have you been in contact with someone with possible or known COVID illness in the last 14 days? or Are you living with someone who is in self-isolation for COVID exposure?*

Yes
No

Are you currently in self-isolation due to COVID exposure or infection?*

Yes
No

Have you returned from travel outside Canada in the last 14 days?*

Yes
No

Have you received any COVID vaccines?*

Yes- both completed, I will bring the dates to my appointment.
Yes- one completed. I will bring the date to my appointment.
No.

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