Covid 19 screening question
This mandatory screening is to protect the health of our patients and Northern Pain Centre Personnel Please Circle Yes or No

1. Do you have a fever or Respiratory Symptoms? Yes No Symptoms include fever OR an acute respiratory infection and include (but are not limited to) cough, sore throat, fatigue and shortness of breath with or without a fever.

2. Have you been identified as a close contact of a confirmed case of novel coronavirus? Yes No A close contact is someone who has been face to face for at least 15 minutes, or been in the same closed space for at least 2 hours, as someone who has tested positive for the COVID-19 when that person was infectious