GP COVID-19 Questionnaire

Name*

First Last

Email*

Date*

Please only fill this form out on the morning of your trip pickup date

In the 14 days prior to your pick up date, have you:

Travelled outside of Canada?*

Yes
No

Been in close contact with someone who has a confirmed or probable case of COVID-19?*

Yes
No

Been in close contact with a person with an acute respiratory illness who has been outside of Canada within 14 days prior to the onset of their illness?*

Yes
No

In the 7 days prior to your pick up date, have you experienced any of the following symptoms?

Body temperature of 38C (100.4F) or higher*

Yes
No

Cough*

Yes
No

Difficulty breathing or shortness of breath*

Yes
No

Malaise*

(Severe fatigue or feeling of being generally unwell)

Yes
No

I confirm that I have answered 'No' to all the questions above*

cannot confirm

Please send us an e-mail to discuss (team@godspocket.com)

I confirm that I have answered 'No' to all the questions above*

confirm

GP COVID-19 Health Questionnaire

COVID-19 Questionnaire

In the 14 days prior to your pick up date, have you:

In the 7 days prior to your pick up date, have you experienced any of the following symptoms?