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COVID 19 QUESTIONNAIRE
Are you currently experiencing any cold or flu-like symptoms? Such as:
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New onset or worsening of existing cough Fever (38°C or 100.4 F)
Shortness of breath or trouble breathing
Sore throat
Severe fatigue
Runny nose
Vomiting
None of the above
Have you travelled to any countries outside Canada (including the United States) within the last 14 days?
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Yes
No
Did you provide care or have close contact with a person with COVID-19 (probable or confirmed) while they were ill (cough, fever, sneezing, or sore throat) within the last 14 days?
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Yes
No
Have you or anybody in your home had contact with someone who is being tested for COVID-19 or who has been diagnosed with COVID-19.
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Yes
No
I agree to receiving marketing and promotional materials
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How did you hear about this site?
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Internet Search
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Friend
Other
If Other please specify:
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What is your age?
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Less than 13
13-18
19-25
26-35
36-50
Over 50
Prefer not to say
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Reason of the Visit
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Routine
Vision problems
Headache
Glasses or contact lens
If Other please specify:
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DO YOU HAVE ANY OF
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Double Vision
Flashes
Floaters
Colour Blindness
Eye Injury or Surgery
Diabetes
Others
IS THERE ANY FAMILY HISTORY OF:
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GLAUCOMA
DIABETES
MACULAR DEGENERATION
EYE DISEASES
GENERAL DISEASES
Other
I agree to receiving marketing and promotional materials
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