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?* No Yes Difficulty breathing?* No Yes New or worsening cough?* No Yes Travelled outside of Canada?* No Yes Been in close proximity to a person with flu like symptoms?* No Yes Flu-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)?* No Yes STOP - Please DO NOT come to the office and contact your family doctor or Peel Public Health.PhoneThis field is for validation purposes and should be left unchanged.