COVID-19 Screening Questionnaire Email Name: * Date: Screened by: Please answer all of the following questions honestly Do you have any of the these current symptoms of COVID-19: Fever? * Yes No New or Changed Chronic Cough? * Yes No Sore throat that is not related to a known or preexisting condition? * Yes No Runny nose that is not related to a known or preexisting condition? * Yes No Nasal congestion that is not related to a known or preexisting condition? * Yes No Shortness of breath that is not related to a known or preexisting condition? * Yes No Have you traveled internationally within the last 14 days? * Yes No Have you had unprotected close contact with individuals who have confirmed or presumptive diagnosis of COVID-19 (e.g. individuals exposed without appropriate PPE in use)? * Yes No I understand that Chiropractic Wellness Centre has the right to refuse seeing me if I have answered YES to any of the above questions:
