COVID-19 Self Assessment Screening Questionnaire

1. Did you received your final (or second) vaccination dose more than 14 days ago? If “Yes”, skip to question 3, if “No”, please proceed to question 2.

2. Have you travelled outside of Canada in the past 14 days?

3. Have you had close contact with a confirmed case of COVID-19 without wearing the appropriate PPE?

4. Do you have any of the following symptoms:

• • Fever and/or chills
  • New onset of cough
  • Worsening chronic cough
  • Shortness of breath
  • Decrease or loss of sense of taste or smell
  • Headache that is unusual or long lasting
  • Unexplained fatigue/lethargy/malaise/muscles aches (if 18 years old or older)
  • Nausea/vomiting, diarrhea (and less than 18 years old)

5. Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?

If you responded YES to any of the above questions except item one, please consider speaking with your MD/local public health authorities, and you must delay your appointment.