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