COVID Questionnaire

Name*

First Last

In the past 14 days have you experienced any of the following:

Fever?*

Difficulty breathing?*

New or worsening cough?*

Travelled outside of Canada?*

Been in close proximity to a person with flu like symptoms?*

Flu-like symptoms include fever, cough, muscle aches, fatigue, or difficulty breathing

Been in contact with anyone with a confirmed OR probable cause of COVID-19 (Coronavirus)?*

STOP - Please DO NOT come to the office and contact your family doctor or Peel Public Health.

Name

This field is for validation purposes and should be left unchanged.