In order to ensure the safety of our patients and staff, and to ensure that the clinic can remain open, you must answer the following questions. You will be required to fill out a paper copy upon arriving at the clinic.

Thank you for your understanding!

COVID-19 Screening Questions

In order for you to be seen today by your healthcare practitioner, you must meet the following criteria:

Are you experiencing any of the following symptoms with unknown cause? 

  • fever
  • new onset of cough
  • worsening chronic cough
  • shortness of breath
  • difficulty breathing
  • sore throat
  • difficulty swallowing
  • decreased or loss of sense of smell
  • chills
  • headaches
  • unexplained fatigue/malaise/muscle aches (myalgias)
  • nausea/ vomiting/ diarrhea/ abdominal pain
  • pink eye (conjunctivitis)
  • runny nose/ nasal congestion without other known cause

Have you had contact with any person with, or under investigation for, COVID-19 in the last 
14 days?                      

Have you or anyone from your household travelled outside of Canada in the last 14 days?

If you were directed to self-quarantine for 14 days post-travel/exposure risk, indicate the
start date: ______________________ and the end date: _________________________

If you are 70 years of age or older, are you experiencing any of the following symptoms; delirium, unexplained or increased number of falls, acute functional decline or worsening of chronic conditions?