Covid Questionnaire

Did the person hove close contact with anyone with acute respiratory illness or travelled outside Ontario in the last 14 days? *

Yes

No

Does the person have a confirmed case of Covid-19 or had contact with a confirmed case of COVID-19? *

Yes

No

Did you receive your final Covid-19 vaccination more than 14 days ago? *

Yes

No

Does the person have any of the following symptoms? *

Fever or a temperature of 38t or 100.4'F or higher

New onset of cough

Worsening chronic cough

Shortness of breath

Difficulty breathing

Sore throat

Difficulty swallowing

Decrease or loss of sense of taste or smell

Chills

Headaches

Unexplained fatigue/malaise /muscle aches (myalgias)

Nausea/vomiting/diarrhea/abdominal pain

Pink eye (conjuntivitis)

Runny nose/nasal congestion without other known cause

No symptom present

If the person is 70 years or older are they experiencing any of the following symptom: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? *

Yes

No

Under 70

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