COVID-19 Screening Questionnaire

We are looking forward to seeing you in our pharmacy! To maintain the safety of our clients and staff we require that you complete a COVID-19 screening questionnaire. This questionnaire has been designed to assess the health of our clients and to determine whether in-person appointments are appropriate at this time.

We ask that you complete this COVID-19 screening questionnaire within twenty four hours of visiting the clinic for your appointment to ensure updated information about your health:

Full Name:*

Please include your full name.

E-mail Address:*

Please include a valid email address.

Phone Number:*

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Have you had difficulty breathing (shortness of breath) in the past 10 days?*

YesNo

Please select

Have you had a cough in the past 10 days?*

YesNo

Please select

Have you had a sore throat in the past 10 days?*

YesNo

Please select

Have you had a fever or chills or flu/cold achiness in the past 10 days?*

YesNo

Please select

Have you had any other cold symptoms like a stuffy or runny nose in the past 10 days?*

YesNo

Please select

Have you experienced flu like gastrointestinal symptoms (diarrhea, nausea, vomiting) in the past 10 days?*

YesNo

Please select

Have you travelled outside of Canada (including the United States) or have had close contact with anyone who has travelled outside of Canada (including the United States) in the past 14 days?*

YesNo

Please select

Have you been diagnosed with or are awaiting test results for COVID-19?*

YesNo

Please select

Have you provided care or had close contact with a person with confirmed COVID-19?*

YesNo

Please select

By checking this box, you agree that you have provided your honest answers, to the best of your knowledge.*

I answered the COVID-19 Screen honestlyI have further concerns and will contact the clinic immediately at 250-477-6112

Please select

*

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