Have you had close contact with anyone with acute respiratory illness or travelled outside Ontario in the past 14 days?
□ Yes □ No
Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?
□ Yes □ No
Do you have any of the following symptoms:
□ Fever
□ New onset cough
□ Worsening chronic cough
□ Shortness of breath
□ Difficulty breathing
□ 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 (conjunctivitis)
Runny nose/nasal congestion without other known cause