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604 291 6666
3995 Hastings Street, Burnaby, BC V5C 2H8
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COVID-19 Self Assessment Tool
Please complete the following COVID-19 self assessment questionnaire prior to your next visit at.
Are you experiencing any of the following:
• Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)
• Severe chest pain
• Having a very hard time waking up
• Feeling confused
• Losing consciousness
• Mild to moderate shortness of breath
• Inability to lie down because of difficulty breathing
• Chronic health conditions that you are having difficulty managing because of difficulty breathing
Yes
no
Are you experiencing cold, flu or COVID-19-like symptoms, even mild ones?
• Symptoms include: fever, chills, cough, shortness of breath, sore throat and painful swallowing, stuffy or runny nose, loss of sense of smell, headache, muscle aches, fatigue or loss of appetite.
Yes
No
Have you travelled to any countries outside Canada (including the United States) within the last 14 days?
Yes
No
Did you provide care or have close contact with a person with confirmed COVID-19?
Note: This means you would have been contacted by your health authority’s public health team
Yes
No
Please prove you are human by selecting the
Star
.
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