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Patient Wellness Screening
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Patient Wellness Screening
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Name
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First
Last
Email
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Are you unvaccinated against COVID-19 (ie. you have NOT had your final/second shot or you have had your second shot less than 14 days ago)?
*
Yes
No
Have you traveled outside of Canada in the past 14 days?
*
Yes
No
Have you tested positive for COVID-19 in the past 10 days or told you should be isolating?
*
Yes
No
Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE in the last 14 days?
*
Yes
No
Fever over 38°C (100.4°F) or chills?
*
Yes
No
New onset of cough?
*
Yes
No
Worsening Chronic cough?
*
Yes
No
Shortness of breath or other difficulties breathing?
*
Yes
No
Decrease or loss of taste or smell?
*
Yes
No
If adult >18 years of age: Unexplained fatigue/malaise/muscle aches (myalgias)?
*
Yes
No
If child <18 years of age: nausea, vomiting, diarrhea.
*
Yes
No
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