COVID-19 Screening Questions Please enable JavaScript in your browser to complete this form.Name *Email *Date / TimePhone1. Have you had close contact with anyone with acute respiratory illness? *YesNo2. Have you travelled outside of Ontario in the past 14 days? *YesNo3. Do you have a confirmed case of COVID-19? *YesNo4. Have you had close contact with a confirmed case of COVID-19? *YesNo5. Do you have any of the following symptoms:FeverNew onset of coughWorsening chronic coughShortness of breathDifficulty breathingSore throatDifficulty swallowingDecrease or loss of sense of taste or smellChillsHeadachesUnexplained fatigue/malaise/muscle achesNausea/vomiting, diarrhea, abdominal pain, pink eyeRunny nose/nasal congestion without other known cause6. Are you 70 years of age or older, experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? *YesNoSubmit
