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 a confirmed or suspected case of COVID-19?
    In the last 14 days have you, or anyone in your household, been in contact with someone who is a confirmed or suspected case of COVID-19?
    In the last 14 days have you, or anyone in your household, been in a location that has known community spread?
    In the last 14 days have you, or anyone in your household, travelled outside of the Atlantic provinces?

    Do you have any of the following:

    Fever (38 or higher)
    Flu-like symptoms
    New or worsening cough
    Shortness of breath
    Muscle aches

    Do you have any of the following that are unexplained:

    Headache
    Sore throat
    Runny nose
    Hoarse voice
    Diarrhea
    Unusual fatigue
    Loss of sense of smell or taste
    Red, purple, blueish lesions on the feet, toes, or fingers without clear cause
    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.

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