Screening form COVID 19
For the health and safety of our community, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
Name
First Name
Last Name
Birth date
-
Month
-
Day
Year
Please add your birth date
Please state whether you've experienced/are experiencing the following
*
Pre-appointment
In-Office
Have you had fever or felt febrile in the last 14-21 days?
Yes
No
Yes
No
Do you have shortness of breath or difficulty breathing?
Yes
No
Yes
No
Do you have fever or difficulty swallowing?
Yes
No
Yes
No
Do you suffer from a cardiac condition, respiratory disease, diabetes, or auto-immune disease?
Yes
No
Yes
No
Do you have flu-like symptoms, like diarrhea, headaches, body aches (muscle pain) or fatigue?
Yes
No
Yes
No
Did you recently lose the sense of smell or taste?
Yes
No
Yes
No
Have you been in contact with anyone who has tested positive for Covid -19 or suspected of being infected?
Yes
No
Yes
No
Do you suffer from a cardiac condition, respiratory disease, diabetes, or auto-immune disease?
Yes
No
Yes
No
Have you travelled outside of the city in the last 14 days?
Yes
No
Yes
No
Any other pertinent information to add?
Yes
No
Yes
No
Other information to add
I acknowledge that the information I've given is accurate and complete.
Date
-
Month
-
Day
Year
Date
Signature
*
Submit
Should be Empty: