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Covid-19 Safety Questionnaire

Name

First Name

Last Name

Do you have a fever or have felt hot or feverish recently (14-21 days)?

Please provide the required field.

Yes

Are you having shortness of breath or any other difficulties breathing?

Please provide the required field.

Yes

Do you have a cough?

Please provide the required field.

Yes

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Please provide the required field.

Yes

Have you experienced a recent loss of taste or smell?

Please provide the required field.

Yes

Are you in contact with any confirmed Covid-19 positive patients? People with sick family members at home should consider postponing.

Please provide the required field.

Yes

Are you over the age of 60?

Please provide the required field.

Yes

Do you have heart disease, lung disease, kidney disease, diabetes or any other auto-immune disorders?

Please provide the required field.

Yes

Have you traveled in the past 14 days to any regions affected by Covid-19?

Please provide the required field.

Yes

Submit