Screening Form

Name *

First Name

Last Name

Do you have a confirmed case of Covid 19 or had close contact with a confirmed case of Covid 19? *

YES

NO

Have you had close contact with anyone with acute respiratory illness or travelled outside of Ontario during the past 14 days? *

YES

NO

Fever? *

YES

NO

New onset of cough or worsening of a cough? *

YES

NO

Shortness of breath or difficulty breathing? *

YES

NO

Sore throat? *

YES

NO

Difficulty swallowing? *

YES

NO

Decrease or loss of taste or smell? *

YES

NO

Chills or symptoms of the flu including malaise, fatigue, muscle pain? *

YES

NO

Nausea, vomitting, diarrhea, or abdominal pain? *

YES

NO

Pink eye? *

YES

NO

Runny nose or nasal congestion without a known cause? *

YES

NO

Are you 70 years of age or older, and experiencing any of the following: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? *

YES

NO