COVID Questionnaire

    Please answer all questions below. If not completed your appointment may need to be rescheduled. The following information is confidential.

    Do you have new or worsening:

    Fever (chills, sweats, temperature)
    Cough

    OR two of the following:

    Sore throat
    Runny nose/nasal congestion
    Headache
    Shortness of breath or difficulty breathing
    If you answered Yes, to any of the above symptoms you are not allowed to enter the clinic at this time. As per Newfoundland and Labrador Public Health Regulations, you should self-isolate at home, and call 811.
    Have you been diagnosed with COVID-19 or are you waiting test results?
    Have you had close contact with sometime who has had COVID-19 in the last 14 days?
    Have you had close contact with someone who is waiting for their COVID-19 test results?
    Have you or anyone in your household returned from travel outside of Atlantic Canada in the last 14 days?
    Have you or anyone in your household been in a listed potential COVID-19 exposure site?

    I confirm that the information given in this form is true, complete and accurate.