Ontario Ministry of Health COVID-19 Patient Screening ***Updated January 3, 2022***
Your First and Last Name (required)
Today's Date (required)
Vaccination Status
yesno Risk Factors and COVID-19 Exposures In the last 10 days, has someone you live with been sick with symptoms associated with COVID-19? yesno In the last 10 days, has someone you live with tested positive for COVID-19 on a PCR or rapid antigen test? yesno In the last 10 days, have you tested positive for COVID-19 on a PCR or rapid antigen test? yesno In the last 10 days, have you been identified as a "close contact" of someone who currently has COVID-19? yesno Have you been told you should be isolating? yesno In the last 10 days, have you travelled outside Canada? yesno Do you have any of the following COVID-19 symptoms? (please check all that apply) Fever and/or chills yesno New cough or barking cough yesno Shortness of breath yesno Decrease or loss of sense of smell or taste yesno Muscle aches / joint pain yesno Extreme tiredness yesno Sore throat yesno Runny nose with unknown cause (e.g., being out in the cold) yesno New or unusual headache yesno Nausea, vomiting and/or diarrhea yesno Thank you for completing this COVID-19 screening prior to your appointment. We appreciate your help and cooperation.
