COVID 19 Questionnaire

Name*

First Last

Phone*

Email

Please answer all the COVID 19 related questions below and hit SUBMIT. Thank you.

Do you have a confirmed case of COVID-19 or have you been in close contact with a confirmed case of COVID-19?*

YES
NO

Have you had close contact with anyone with acute respiratory illness?*

YES
NO

Have you travelled outside of Canada in the past 14 days?*

YES
NO

Please check any of the following symptoms you currently have:*

If you do NOT have any of the above symptoms, please check the first option.

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?

As a person over 70 years of age, are you experiencing the above symptoms?

YES
NO

Please Fill Out This Ministry Of Health COVID-19 Screening Questionnaire

COVID 19 Questionnaire: