COVID-19 Questionnaire

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Covid-19 Questionnaire

First Name*
Last Name*
Phone*

Please identify if you are experiencing any of the following:
A fever*
Muscle aches or chills*
Shortness of breath*
Difficulty breathing*
Sore throat*
Runny nose*
Have travelled outside Canada within the past 14 day*
Been in contact with anyone that is being*
Monitored or confirmed coronavirus infection*

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