Covid-19 Screening - Family Chiropractic Centre

First Name *

Last Name *

Email Address

Phone Number *

Fever or chills *

NoYesNo

Difficulty breathing or shortness of breath *

NoYesNo

New onset of cough or worsening chronic cough *

NoYesNo

Decrease or loss of taste or smell *

NoYesNo

If adult >18 years of age: Unexplained fatigue/lethargy/malaise/muscle aches

NoYesNo

If child <18 years of age: Nausea, vomiting, diarrhea

NoYesNo

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

NoYesNo

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

NoYesNo

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

NoYesNo