COVID-19 Screening Questionnaire

Please correct the errors described below.

Client Information

First name

Last name

Email address

Phone number

Appointment Information

You must complete this COVID-19 screening questionnaire before each visit to our office on the day of your visit. Please confirm today's date and the date of your appointment.

Today's date

Date of your appointment

Symptom History

Have you experienced any of the following symptoms in the past 14 days?

Fever or chills

Yes No

Cough

Yes No

Shortness of breath or difficulty breathing

Yes No

Unexplained fatigue, lethargy, malaise, muscle aches

Yes No

New loss of taste or smell

Yes No

Nausea, vomiting or diarrhea

Yes No

Vaccination Status

Did you received your second COVID vaccine more than 14 days ago?

Yes No

Contact History

Does anyone in your household have one or more symptoms of COVID-19 and/or are waiting for test results after having symptoms?

Yes No

In the past 14 days have you been notified as a close contact of someone with COVID-19 or been told to self-isolate at home?

Yes No

Travel History

In the past 14 days have you travelled outside of Canada?

Yes No

Please complete this questionnaire again if any of your answers change before your appointment.

If you have responded yes to any of the above questions, other than regarding your vaccine status, please contact our office by telephone to discuss the appropriate next steps.

Your information will be encrypted.

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Clear

Drop image file here or click to select file Click here to select image file from your computer

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Use this signature or Cancel

Hushmail

Hide