Patient Screening Form

    Have you received your final (or second) vaccination dose more than 14 days ago?


    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

    • 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?