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?
Cough
*
Yes
No
Fever and/or chills
*
Yes
No
Sore throat, trouble swallowing
*
Yes
No
Shortness of breath/breathing difficulties
*
Yes
No
Loss of taste or smell
*
Yes
No
Vomiting or diarrhea for more than 24 hours
*
Yes
No
Sore muscles and/or lethargy
*
Yes
No
Travel / Contact
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
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