COVID-19 Questionnaire

    Before your appointment or before the home or office visit

    Identification of the client or designated person:



    Form completed by:

    Date of the appointment:

    COVID-19 Questionnaire

    Have you received a positive result from a COVID-19 test or a recommendation to take a COVID-19 test or are awaiting results from a COVID-19 test?

    Are you experiencing a fever, chills similar to those of the flu, or a fever with a temperature taken orally of 38ºC / 100.4ºF or greater?

    Are you experiencing a cough that is recent or that has recently gotten worse, difficulty breathing or shortness of breath?

    Are you experiencing a sudden loss of smell or taste?

    Are you experiencing abdominal pain?

    Are you experiencing nausea / vomiting?

    Are you experiencing diarrhea?

    Are you experiencing a sore throat?

    Are you experiencing a runny nose or nasal congestion?

    Are you experiencing extreme fatigue?

    Are you experiencing a significant loss of appetite?

    Are you experiencing muscle aches (not attributed to physical effort)?

    Do you have a known health condition that could explain the symptoms you reported above?

    Have you been in close contact (for at least 15 minutes and closer than 2 metres apart) with someone with a confirmed or suspected case of COVID-19?