Health Check Name* First Last Birthdate* MM slash DD slash YYYY Do you have a fever or have felt hot or feverish anytime in the last two weeks?* Yes No Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Sneezing? Post-nasal drip?* Yes No Have you experienced a recent loss of smell or taste?* Yes No Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?* Yes No Have you returned from travel outside of Canada in the last 14 days?* Yes No Have you returned from travel within Canada from a location known affected with COVID-19?* Yes No Is your workplace considered high risk?* Yes No Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder,COPD, any chance of pregnancy?* Yes No If you have answered YES to any of the questions above please call our office directly. CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
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