Covid 19 survey | Macleod Trail Dental

Name*
First Last
Email*
Do you have a fever or have felt hot or feverish anytime in the last 10 days?*
- Yes
- No
Do you have any of the following symptoms: new cough or worsening cough? New shortness of breath or worsening shortness of breath? Difficulty breathing? Sore throat or painful swallowing? Flu-like symptoms? Runny nose?*
- Yes
- No
Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of determined risk for COVID-19?*
- Yes
- No
Have you returned from travel outside of Canada in the last 14 days?*
- Yes
- No
Have you lost your sense of smell?*
- Yes
- No
Have you returned from travel within Canada from a location known affected with COVID-19 in the last 14 days?*
- Yes
- No
Is your workplace considered high risk? (e.g. routine close contact with many people)*
- Yes
- No