Firstname   Lastname  
Street Address  
Address Line 2
City   Province  
Postal Code   Phone Number  
Email Address  

PATIENT QUESTIONNAIRE
1. Have you traveled anywhere recently in the past 14 days?  
2. Have you been in contact with anyone who was sick or diagnosed with COVID-19, or who was in contact with anyone who was sick or diagnosed with COVID-19?  
3. Have you attended any large group functions?  
4. Have you had any of the following symptoms within the last two weeks: fever, fatigue, dry cough, altered taste, altered smell, trouble breathing, productive cough (mucous in cough), or muscle pain?  
5. Have you previously had the SARS-COV-2 virus (novel coronavirus)? Did you test positive?  
6. Are you over the age of 65?  
7. Do you have any pre-existing health conditions related to any of the following  
   

Please sign your signature above.