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COVID-19 HEALTH QUESTIONNAIRE

First Name*

Last Name*

Do you have any of the following NEW OR WORSENING symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.

Fever or chills in the last two weeks.

Select an option

Cough, shortness of breath, difficulty breathing, sore throat, runny nose/stuffy nose or nasal congestion.

Select an option

Recent decrease or loss of smell or taste.

Select an option

Nausea, vomiting, diarrhea, abdominal pain.

Select an option

Have you been in contact with any confirmed or probable COVID-19 positive patients or a person self-isolating because of a determined risk for COVID-19?

Select an option

Have you returned from travel outside of Canada in the last 14 days?

Select an option

Please note that-

If you have answered 'Yes' to any of the above questions, then please call or email our office to provide us with more details PRIOR to arriving for your appointment. We can be reached at 613¬591-1638 or drsim@primus.ca.

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