COVID Questionnaire Name* First Name Family Name Would your mental health be compromised if you DID NOT attend this appointment?* Yes No Are you currently required to be in isolation because you have been diagnosed with coronavirus (COVID-19)?* Yes No Have you been directed to a period of 14-day quarantine by the Department of Health and Human Services as a result of being a close contact of someone with coronavirus (COVID-19)?* Yes No Have been to any Tier 1 or Tier 2 exposure sites in the last 3 weeks?* Yes No Are you experiencing any of these symptoms?*Fever (above 37.5°C) Chills Cough Sore throat Shortness of breath Runny nose Loss of sense of smell Aching muscles Yes No Δ
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