3818 Line 11 North, Oro-Medonte, ON
(705) 329-0216
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COVID-19 Screening Questionnaire
First Name
*
Last Name
*
Pet's Name
*
Do you have new, onset or worsening symptoms of any of the following symptoms?
Fever and/or Chills
*
Yes
No
Difficulty Breathing/Shortness of Breath
*
Yes
No
Cough/Barking Cough
*
Yes
No
Decrease or Loss of Smell or Taste
*
Yes
No
Nausea, Vomiting, Diarrhea, Abdominal Pain
*
Yes
No
Travel / Contact
Has a healthcare provider told you to self-isolate?
*
Yes
No
Have you traveled outside of Canada in the past 14 days?
*
Yes
No
Have you had close contact with a confirmed or probable case of COVID-19?
*
Yes
No
Have you tested positive for COVID-19 in the past 10 days?
*
Yes
No
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