Have you travelled outside of Canada in the past 14 days? Have you travelled outside of Canada in the past 14 days? Yes No

Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? Yes No

Do you have any of the following symptoms: Fever • Cough • Worsening cough • Shortness of breath • Difficulty breathing • Sore throat • Difficulty swallowing • Decreased or loss of sense of taste or smell • Chills • Headaches • Unexplained fatigue/malaise/muscle aches • Nausea/vomiting, diarrhea, abdominal pain • Pink eye • Runny nose/nasal congestion with unknown cause Do you have any of the following symptoms: Fever • Cough • Worsening cough • Shortness of breath • Difficulty breathing • Sore throat • Difficulty swallowing • Decreased or loss of sense of taste or smell • Chills • Headaches • Unexplained fatigue/malaise/muscle aches • Nausea/vomiting, diarrhea, abdominal pain • Pink eye • Runny nose/nasal congestion with unknown cause Yes No

If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? Yes No

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