Screening Form Patient Full Name* Patient Age PhoneEmail Are you Fully Vaccinated against COVID-19 or aged 11 and/or younger? Yes No In the last 14 days, have you travelled outside of Canada and NOT been exempt from federal quaratine rules? Yes No In the last 5 days (if fully vaccinated) / 10 days (if unvaccinated or immunocompromised), have you experienced any of these symptoms? Yes No In the last 5 days (if fully vaccinated) / 10 days (if unvaccinated or immunocompromised), have you experienced any of these symptoms? Fever and/or chills Cough or barking cough Shortness of breath Decrease or loss of taste or smell Muscle aches/joint pain Sore throat Extreme tiredness Runny or stuffy/congested nose Headaches Nausea,vomiting and/or diarrhea Do any of the following apply? You live with someone who is currently isolating because of positive COVID-19 test You live with someone who is currently isolating because of positive COVID-19 symptoms You live with someone who is currently isolating while waiting for COVID-19 test results In the last 5 days (if fully vaccinated) / 10 days (if unvaccinated or immunocompromised), have you tested positive on rapid antigen test, molecular test, or home-based self testing kit? Yes No In the last 5 days (if fully vaccinated) / 10 days (if unvaccinated or immunocompromised), have you tested positive on rapid antigen test, molecular test, or home-based self testing kit? Yes No Has a doctor, health care provider or public health unit told you that you should currently be isolating (staying at home)? Yes No CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
