COVID-19 Questionnaire COVID 19 Questionnaire Name* Please check off all the questions that you answer YES to 1. Do you have a fever or have felt hot or feverish anytime in the last two weeks (5 days)? 2. Do you have any of the following symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? 3. Have you experienced a recent loss of smell or taste? Please Call us at 905-294-6444 if you have answered yes to any of these questions
