Patient Name* First Last Phone Number:*Birthdate* MM slash DD slash YYYY E-mail Address* Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Covid-19 Prescreening QuestionsHave you had close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?* Yes No Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19?* Yes No Do you have any of the following symptoms?* I have none of these symptoms Fever New onset of 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 (myalgias) Nausea/vomiting, diarrhea, abdominal pain Pink eye (conjunctivitis) Runny nose/nasal congestion without other known cause Do you have any of these additional symptoms?* I have none of these symptoms Delirium Unexplained or increased number of falls Acute functional decline Worsening of chronic conditions Signature*Date of Application* MM slash DD slash YYYY Δ
