MTS Paralegal Services | COVID-19 Survey

Meeting Date *

Name *

Email *

Required Screening Questions

1. Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.

Fever or chills *

Yes

No

Difficulty breathing or shortness of breath *

Yes

No

Cough *

Yes

No

Sore throat, trouble swallowing *

Yes

No

Runny nose/stuffy nose or nasal congestion *

Yes

No

Decrease or loss of smell or taste *

Yes

No

Nausea, vomiting, diarrhea, abdominal pain *

Yes

No

Not feeling well, extreme tiredness, sore muscles *

Yes

No

Travel

2. Have you travelled outside of Canada in the past 14 days? *

Yes

No

Close Contact

3. Have you had any close contact with a confirmed or probable case of COVID-19? *

Yes

No

If you have any other comments or concerns, please let us know in the field below:

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