COVID-19 Patient Pre-Screening QuestionnaireThe following form must be filled out only 24 hours before your appointment and is mandatory. If you answer ‘YES’ to any of the questions, DO NOT ENTER this building. Do you have ONE (1) of the symptoms that are not related to a known pre-existing health condition (i.e., seasonal allergies)? If YES, you should be tested for COVID-19. If you are experiencing any symptoms, you should get tested. You can register for a test online by clicking ‘Get tested’ on the GNB Coronavirus website, calling Tele-Care 811 or by contacting your primary health-care provider. For the latest information visit: www.gnb.ca/coronavirusPlease enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth *yyyy-mm-ddHave you been advised by Public Health, a health-care provider or a peace officer that you are currently required to self-isolate? *YesNoAre you waiting for a COVID-19 test or COVID-19 test results AND have been told you need to self-isolate? *YesNoHas an individual in your household returned from outside of the province in the past 14 days for any reason, and now someone within the household has developed one or more symptoms of COVID-19 as listed above? *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? *YesNoPhoneSubmit
