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Covid-19 Client Records
Covid-19 Client Form
1. Do you have any of the following new or worsening symptoms or signs?
Symptoms should not be chronic or related to other known causes or conditions.
Fever or chills
*
yes
no
Difficulty breathing or shortness of breath
*
yes
no
Cough
*
yes
no
Sore throat, trouble swallowing
*
yes
no
Runny nose/stuffy nose or nasal congestion
*
yes
no
Decrease or loss of smell or taste
*
yes
no
Nausea, vomiting, diarrhea, abdominal pain
*
yes
no
Not feeling well, extreme tiredness, sore muscles
*
yes
no
2. Have you travelled outside of Canada in the past 14 days?
*
yes
no
3. Have you had close contact with a confirmed or probable case of COVID-19?
*
yes
no
Name
*
First
Last
Date
*
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