Pre-Screening Form— COVID-19
1.) Have you or anyone in your household been outside of Ontario in the last two weeks (14 days)?
□ Yes □ No
2.) Are you exhibiting any of the following symptoms (Check all that apply):
-
- Cough or worsening of a previous cough
- Fever Loss of smell and/or taste
- Runny nose or nasal congestion
- Shortness of breath
- Muscles aches
- Sore Throat
- Unusual fatigue
- Diarrhea
- Red, purple or blueish lesions, on the feet, toes or fingers without clear cause
- None
3.) Have you been in contact with anyone who is exhibiting any of the symptoms listed above?
□ Yes □ No
4.) Have you, or anyone you have been in contact with, been diagnosed with COVID-19?
□ Yes □ No