COVID-19 Patient Pre-Screening QuestionnaireThe following form must be filled out only 24 hours before your appointment and is mandatory.Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth *yyyy-mm-ddHave you been diagnosed with COVID-19 and since recovered? *YesNoHave you been diagnosed with COVID-19, or are waiting to hear the results of a lab test for COVID-19? *YesNoHave you been told by public health that you may have been exposed to COVID-19? *YesNoHave you travelled outside New Brunswick in the last 14 days? *YesNoIf YES, where have you travelled to in the last 14 days? Are you experiencing fever above 38 degrees Celsius? *YesNoAre you experiencing a new cough, or worsening chronic cough? *YesNoAre you experiencing a sore throat? *YesNoAre you experiencing a runny nose? *YesNoAre you experiencing a headache? *YesNoAre you experiencing a new onset of fatigue? *YesNoAre you experiencing a new onset of muscle pain? *YesNoAre you experiencing diarrhea? *YesNoAre you experiencing loss of sense of taste? *YesNoAre you experiencing loss of sense of smell? *YesNoIn children, Are you experiencing purple markings on the fingers and toes? *YesNoWebsiteSubmit
