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
      (myalgias)
    • If child < 18 years of age: nausea/vomiting, diarrhea
    YesNo
    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?
    YesNo
    Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
    YesNo