Patient Name:
Email Address:
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
Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?
Did you travel outside of Canada in the past 14 days?
Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
