Name *

First Name

Last Name

Have you been out of the country in the past 14 days? *

Yes

No

Are you experiencing any of the following: *

• Severe difficulty breathing (e.g. struggling to breathe or speak) • Severe chest pain • Having a very hard time waking up • Feeling confused • Losing consciousness

Yes

No

Are you experiencing any of the following: *

• Fever • Cough • Sore throat • Runny nose • Headache

Yes

No

Within the last 14 days did you provide care or have close contact with a symptomatic person known or suspected to have COVID-19? *

Yes

No

Did you have close contact with a person who travelled outside of Canada in the last 14 days who has become ill (fever, cough, sore throat, runny nose or headache)? *

Yes

No