Patient name *

Does the patient have a fever or have you/they felt hot or feverish recently (the last 14 days)? *

Do you have shortness of breath or other difficulties breathing, new onset of cough, worsening of chronic cough? *

Do you have any of the following symptoms; sore throat, difficulty swallowing, decrease or loss of sense of taste or smell, chills, headaches, unexplained fatigue/malaise/muscle aches, nausea/vomiting, diarrhea, abdominal pain, pink eye, or runny nose/nasal congestion that is not allergy related? *

Has the patient tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

Has the patient travelled outside of Ontario or had close contact with anyone that has travelled outside of Ontario in the past 14 days? *

Has the patient been directed by a health care provider including public health official to isolate? *

Have you read the information below? *