Back to School with Mask

Screening Questionnaire


Please complete the following COVID-19 Screening Questionnaire prior to each appointment at the clinic.


Thank you for helping us limit the spread of COVID-19.


Covid-19 Screening

How are you feeling today?

Please complete on the SAME day as your appointment.

If you/your child currently has COVID-19 symptoms or have been in contact with a suspected/confirmed case of COVID-19, please contact your assigned clinician directly as soon as possible. Do not present yourself to the clinic. Please follow Ontario's guidelines:

Do you/Does your child currently have a fever of 37.8 degrees Celcius or greater?
Have you/your child been in close contact with anyone with a respiratory illness or a suspected/confirmed case of COVID-19?
Are you/Is your child currently experiencing any COVID-19 related symptoms (cough, shortness of breath, sore throat, runny nose, difficulty swallowing, loss of taste/smell, nausea/vomitting, unexplained fatigue, chills and/or headache)?
Your clinician:

Thanks for submitting!