Do you have a fever or have felt hot or feverish anytime in the last two weeks? * No Yes
Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? * No Yes
Have you experienced a recent loss of smell or taste? * No Yes
Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19? * No Yes
Have you returned from travel outside of Canada in the last 14 days? * No Yes
Have you returned from travel within Canada from a location known affected with COVID-19? * No Yes
Are you over the age of 60? * No Yes
Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder? * No Yes