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1. Do you have a fever?

☐ Yes    ☐ No

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2. Do you have any of the symptoms listed below?

☐ New onset of cough   

☐ Worsening chronic cough
☐ Sore throat

☐ Shortness of breath
☐ Difficulty breathing

☐ Runny nose 

☐ Nasal congestion

☐ New loss or decrease in sense of taste or smell
☐ Sneezing   

☐ Hoarse voice   

☐ Chills   

☐ Headache
☐ Unexplained fatigue or malaise   

☐ Difficulty swallowing
☐ Nausea/vomiting, diarrhea, abdominal pain

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3. Have you attended any events or gatherings outside of your family/social bubble within the past 14 days?

☐ Yes    ☐ No

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4. Have you travelled outside of the Lower Mainland or have had close contact with anyone who has travelled in the past  14 days?

☐ Yes    ☐ No

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4. At the time of your appointment will you have been recommended by a health authority to self-isolate for 14 days?

☐ Yes    ☐ No

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5. Have you had close contact with anyone with respiratory illness or a confirmed or probable/suspected case of COVID-19?

☐ Yes   ☐ No

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6. Did you wear the required and/or recommended PPE according to the type of duties you were performing (e.g., goggles, gloves, mask and gown or N95 with aerosol generating medical procedures when you had close contact with a suspected or confirmed case of COVID-19?

☐ Yes    ☐ No