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COVID-19 SELF-ASSESSMENT
Dr. Else H. Larsen
104 - 3077 Granville Street
Vancouver, BC, V6H 3J9
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* Indicates required question
If you are unsureĀ
1. Have you recently experienced any of the following?:
*
New or worsening cough
Sore throat
Shortness of breath or difficulty breathing
Fever or chills
Recent loss or decrease in sense of smell or taste
Runny nose or sneezing (not allergy related)
Unexpected fatigue
Difficulty swallowing
Nausea/vomiting, diarrhea or abdominal pain
None of the above
Required
2. In the last 14 days, have you traveled outside of Canada?
*
Yes (and have received a negative COVID-19 test upon my return)
Yes (and have not been tested upon my return)
No
3. In the last 14 days, have you had close contact with a person who:
*
Has a sore throat, cough, fever, runny nose, sneezing, shortness of breath, or any other symptom associated with COVID-19
Has been diagnosed with COVID-19
Has travelled outside of CANADA in the past 14 days and did NOT receive a negative COVID-19 test upon return
None of the above
Required
If you answered anything other than "None of the above" or "No" for Questions 1 to 3, please call our office at 604-732-3422 to discuss. For the safety of our patients and staff your appointment may be rescheduled, and it is recommended for you to stay home and self isolate. Pay attention to your health and how you are feeling. You can call 8-1-1 anytime to talk to a nurse at HealthLinkBC and get advice on what to do next.
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