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
