Ontario Ministry of Health COVID-19 Patient Screening Updated August 26, 2021
Your First and Last Name (required)
Today's Date (required)
Did you receive your final (or second) vaccination dose more than 14 days ago? yesno
Have you travelled outside Canada in the last 14 days? yesno
Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? yesno
Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating? yesno
Do you have any of the following COVID-19 symptoms? (please check all that apply)
Fever and/or chills yesno
New onset of cough or worsening chronic cough yesno
Shortness of breath yesno
Decrease or loss of sense of smell or taste yesno
If an adult >18 years of age: unexplained fatigue/lethargy/malaise/muscle aches yesno
If a child <18 years of age: nausea/vomiting, diarrhea yesnon/a
Thank you for completing this COVID-19 screening prior to your appointment. We appreciate your help and cooperation.
