COVID-19 Pre-Screening Form Please fill out the form below 7 days prior to your appointment: Your Name: Your Appointment Date: Have you tested positive for COVID-19? YesNo Are you awaiting results for a COVID-19 test? YesNo Do you have a fever over 37.8°C (100.4°F) or chills? YesNo Do you have a new or worsening cough? YesNo Do you have a sore throat?YesNo Do you have a runny nose or nasal congestion that you wouldn't normally have because of seasonal allergies or another pre-existing condition?YesNo Do you have other cold- or flu-like symptoms? YesNo Are you having new or worsening shortness of breath or other difficulties breathing? YesNo Have you experienced a recent loss of taste or smell? YesNo Are you feeling tired or fatigued without explanation? YesNo Do you have a new or worsening headache? YesNo Do you have nausea, vomiting, diarrhea or abdominal pain? YesNo Even if you do not currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?YesNo Have you returned from travel outside of Canada in the past 14 days?YesNo Signature: Press the button below to submit the completed screening form.