COVID-19 Daily Screening Questionnaire

Please complete the following questions before entering the office today:

  • DD slash MM slash YYYY
  • Select all that apply.
  • Select all that apply.


If you answered YES to any of these questions, please return home and self-isolate.
Visit for more information about getting tested.

Continue to monitor yourself for symptoms of COVID-19 and other general symptoms including sore throat, difficulty swallowing, runny or stuffy/congested nose, abdominal (stomach) pain, headache, conjunctivitis (pink eye), or decreased or lack of appetite.

If you are feeling sick, please stay at home until symptoms are improving for 24 hours without the use of fever-reducing medication.  A full list of COVID-19 and other symptoms for adults can be found on the Ottawa Public Health webpage.  We would also recommend contacting your healthcare provider or call Telehealth Ontario at 1-866-797-0000 to speak to a registered nurse.