COVID-19 health history Name* First Last Date MM slash DD slash YYYY Phone*Email Do you have fever, new onset of cough, worsening chronic cough, shortness of breath, or difficulty breathing? Yes No Have you had close contact with anyone with acute respiratory illness or travelled outside of Canada in the past 14 days? Yes No Do you have a confirmed case of COVID-19 or have had close contact with a confirmed case of COVID-19? Yes No Have you travelled recently? Yes No If you answered yes to any of these questions, please contact our office for further clarification prior to your appointment.