Your Name (required)
Your Email (required) 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? NoYes 2. Have you travelled outside of Canada or Ontario within the past 14 days? NoYes 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? NoYes 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? NoYes 5. Are you currently waiting for Covid-19 test results? NoYes 6. Are you immuno-compromised? NoYes 7. Do you have 2 or more of the following symptoms?
NoYes 8. Do you have any underlying health issues? Ie; diabetes, heart disease, high blood pressure, kidney disease, asthma, COPD (chronic obstructive pulmonary disease) NoYes 9. Have you had any recent surgeries or injuries? NoYes 10. Have you experienced any acute functional declines, falls, worsening of current or chronic conditions? NoYes 11. Do you work in a healthcare environment and/or are exposed to people who are ill? NoYes
