COVID Questionnaire Please fill out this form prior to coming to the office to help us assess if you should visit Dr. Ahmed or your family doctor for your needs. Name* First Last In the past 14 days have you experienced any of the following:Fever?*NoYesDifficulty breathing?*NoYesNew or worsening cough?*NoYesTravelled outside of Canada?*NoYesBeen in close proximity to a person with flu like symptoms?*NoYesFlu-like symptoms include fever, cough, muscle aches, fatigue, or difficulty breathingBeen in contact with anyone with a confirmed OR probable cause of COVID-19 (Coronavirus)?*NoYesSTOP - Please DO NOT come to the office and contact your family doctor or Peel Public Health.