Patient Screening Form

    Have you received your final (or second) vaccination dose more than 14 days ago?YesNo
    Do you have any of the following symptoms?

    • Fever and/or chills
    • New onset of cough or worsening chronic cough
    • Shortness of breath
    • Decrease or loss of sense of taste or smell
    • If adult >18 years of age: unexplained fatigue/lethargy/malaise/ muscle aches
    • If child < 18 years of age: nausea/vomiting, diarrhea
    Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?YesNo
    Did you travel outside of Canada in the past 14 days?
    Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?