Patient's Name * First Name Last Name Contact Email * Contact Phone Number * Did the person have 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 Does the person have any of the following symptoms? * Fever or a temperature of 38’C 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 symptoms present If the person is 70 years or older are they experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? * Yes No Under 70 Did the person receive their final Covid-19 vaccination more than 14 days ago? Yes No Thank you!
