Covid-19 Questionnaire

Please fill out the following form to help us understand your physical condition.

First Name

Fever or Chills?

No

Yes

Last Name

Difficulty Breathing or Shortness of Breath?

No

Yes

Cough?

No

Yes

Decerease or loss of smell or taste?

No

Yes

Nausia, Vomiting, Diarrhea, Abdominal Pain?

No

Yes

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

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Tel: (416) 622-7000

24 Rivalda Road

Toronto, ON M9M 2M3

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