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Zuber & Company LLP in Toronto
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COVID-19 pre-screening form
Contact Us
COVID-19 pre-screening form
COVID-19 pre-screening form
Date
Name
Email
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
2. Have you travelled outside of Canada in the past 14 days?
Yes
No
3. Have you had close contact with a confirmed or probable case of COVID-19?
Yes
No