Coronavirus (COVID-19) Screening Questionnaire

Please provide details prior to your next appointment.

Personal Information:



Screening Questions:

Capital includes both side of the Ottawa river in Ontario & Quebec.


You can choose more than one.

FeverNew onset of coughWorsening chronic CoughShortness of breathDifficulty breathingSore throatDifficulty swallowingDecrease or loss of sense of taste or smellChillsHeadachesUnexplained fatigue / malaise / muscle aches (myalgias)Nausea/vomiting, diarrhea, abdominal painPink eye (conjunctivitis)Runny nose/nasal congestion without other known cause


Patient Declaration:

I/We hereby confirm that the information provided herein is accurate, correct and complete and that the documents submitted along with this application form are genuine.

Yes

Verification

Example: 12