COVID-19 Patient Pre-Screening Questionnaire - Moncton Naturopathic Medical Clinic

COVID-19 Patient Pre-Screening Questionnaire

The following form must be filled out only 24 hours before your appointment and is mandatory.

Name *

First

Last

Date of Birth *

yyyy-mm-dd

Have you been diagnosed with COVID-19 and since recovered? *

Have you been diagnosed with COVID-19, or are waiting to hear the results of a lab test for COVID-19? *

Have you been told by public health that you may have been exposed to COVID-19? *

Have you travelled outside New Brunswick in the last 14 days? *

Have you travelled to the Campbellton area (Zone 5) in the last 14 days? *

Are you experiencing fever above 38 degrees Celsius? *

Are you experiencing a new cough, or worsening chronic cough? *

Are you experiencing a sore throat? *

Are you experiencing a runny nose? *

Are you experiencing a headache? *

Are you experiencing a new onset of fatigue? *

Are you experiencing a new onset of muscle pain? *

Are you experiencing diarrhea? *

Are you experiencing loss of sense of taste? *

Are you experiencing loss of sense of smell? *

In children, Are you experiencing purple markings on the fingers and toes? *

Single Line Text

Name

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