Dr. Cory Torgerson COVID-19 Screening for Access to the Clinic Today's Date: 1/14/2025Current Time: 3:18 PMFull Name*FirstLastEmail Address*Verify Email*NextWithin the last 14 days, have you experienced any of the following symptoms?Severe Cough or New Onset of Cough or Worsening Chronic Cough*YesNoNasal Congestion or Runny Nose or Sore Throat*YesNoFever, Chills or Headache*YesNoMuscle Pains*YesNoDifficulty Swallowing*YesNoShortness of Breath or Difficulty Breathing*YesNoReduced or Lose Sense of Smell*YesNoUnexplained Fatigue*YesNoNausea, Vomiting, Diarrhea or Abdominal Pain*YesNoPink Eye (conjunctivitis)*YesNoBackNextIn the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19?*YesNoIn the last 14 days, have you been in close contact with someone who is currently sick with a new cough, fever, or difficulty breathing?*YesNoIn the last 14 days, have you been in close contact with someone who returned from outside Canada?*YesNoBackNextFinal questionHave you travelled outside of Canada in the last 14 days?*YesNoI acknowledge that I have to attend the appointment by myself due to COVID-19 restrictions. If you are under 18 years of age, you can bring your legal guardian.BackSendThis field should be left blank
