Pre Screening Form COVID-19

Pre-Screening Form—COVID-19


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

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