Covid-19 Pre-Screening Questionnaire Pre-Screening Questionnaire Name * Email * 1. Do you/have you had a fever, new onset of cough, worsening chronic cough, shortness of breath or difficulty breathing within the past 14 days? * No Yes 2. Have you travelled outside of Canada or Ontario within the past 14 days? * No Yes 3. Have you had close contact with anyone with acute respiratory illness or anyone who has travelled outside of Canada or Ontario within the past 14 days? * No Yes 4. Have you been confirmed positive for Covid-19 or have you been in close contact with anyone who has tested positive for Covid-19? * No Yes 5. Are you currently waiting for Covid-19 test results? * No Yes 6. Are you immuno-compromised? * No Yes 7. Do you have 2 or more of the following symptoms? * Sore throat Runny nose/sneezing/nasal congestion Hoarse voice Difficulty swallowing Decrease or loss of smell and/or taste Chills Headache Unexplained fatigue Diarrhea Abdominal pain Nausea and/or vommiting No Yes 8. Do you have any underlying health issues? Ie; diabetes, heart disease, high blood pressure, kidney disease, asthma, COPD (chronic obstructive pulmonary disease) * No Yes 9. Have you had any recent surgeries or injuries? * No Yes 10. Have you experienced any acute functional declines, falls, worsening of current or chronic conditions? * No Yes 11. Do you work in a healthcare environment and/or are exposed to people who are ill? * No Yes reCAPTCHA If you are human, leave this field blank.