COVID-19 Survey

Dr. Alice Wong and Panda Pediatrics

4825 Dalhousie Drive NW403-239-9333

Symptoms Check

Have you experienced any of the following symptoms in the past 48 hours:

Fever or chills
cough
shortness of breath
difficulty breathing
fatigue
muscle or body aches
headache
new loss of taste or smell
sore throat
congestion or runny nose
nausea or vomiting
diarrhea

YES NO

Isolating

Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?

YES NO

Vaccinated / Recovering

Are you fully vaccinated OR have you recovered from a documented COVID-19 infection in the last 3 months?
To be considered fully vaccinated, you must be ≥2 weeks following receipt of the second dose in a 2-dose series or ≥2 weeks following receipt of one dose of a single-dose vaccine.

YES NO

Contact

Have you been in close physical contact in the last 14 days with anyone who is known to have laboratory-confirmed COVID-19 or anyone who has any symptoms consistent with COVID-19?

YES NO

Testing

Are you currently waiting on the results of a COVID-19 test? IMPORTANT: Answer "NO" if you are waiting on the results of a pre-travel or post-travel COVID-19 test.

YES NO

I have answered the above questions truthfully and to the best of my knowledge. I have read and agree to the privacy policy which describes how the submitted information will be used.

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