PATIENT DISCLOSURESPatient Disclosures Please disclose any indication of having been exposed to COVID‐19, or whether you have experienced any signs or symptoms associated with the COVID‐19 virus. Name* First Do you have a fever?YESNODo you have trouble breathing?YESNODo you have a dry cough?YESNODo you have a runny nose?YESNOHave you recently lost or had a reduction in your sense of smell?YESNODo you have a sore throat?YESNOHave you been in contact with someone tested positive for COVID‐19?YESNOHave you tested positive for COVID‐19?YESNOHave you been tested for COVID‐19 and are awaiting results?YESNOHave you traveled outside the Canada by air or cruise ship in the past 14 days?YESNOHave you traveled within the Canada by air, bus or train within the past 14 days?YESNO
