Optional Registration

COVID-19 Survey

Dr. Alice Wong and Panda Pediatrics

4825 Dalhousie Drive NW403-239-9333

Symptoms Check

I have experienced symptoms of COVID-19 in the past 14 days. Symptoms of COVID-19 include, but are not limited to:

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

Testing

I have tested positive for COVID-19 in the past 14 days or I am currently waiting on the results of a COVID-19 test.

YES NO

Contact

I have knowingly been in close or proximate contact in the past 14 days with someone who has tested positive for COVID-19 or has or had symptoms of COVID-19.

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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