COVID-19 Survey – Cassandra Southall RMT

Name *

First

Last

Email *

Do you agree that the novel coronavirus disease resulting in COVID-19 has a long incubation period and can be spread from person to person not displaying any symptoms? *

Yes
No

Do you agree that as a Healthcare Professional I am more susceptible to contracting COVID-19 from other patients I see and may be non-symptomatic? *

Yes
No

Have you travelled outside of British Columbia in the last 14 days? *

Yes
No

Are you currently experiencing any of the following symptoms: fever, chills, cough, shortness of breath, difficulty breathing, sore throat, loss of sense of smell, sneezing (non-allergy related), nasal congestion, random onset of fatigue/malaise, nausea/vomiting, diarrhea, and/or difficulty swallowing? *

Yes
No

Have you been in close contact with anyone who has tested positive for COVID-19 within the last 14 days? *

Yes
No

Have you tested positive for COVID-19 within the last 14 days? *

Yes
No

Do you confirm that you are not waiting for any lab results pertaining to COVID-19? *

Yes
No

Questions about the Survey

COVID-19 Pre-Appointment Survey