Ontario Ministry of Health COVID-19 Patient Screening ***Updated January 3, 2022***
Your First and Last Name (required)
Today's Date (required)
Vaccination Status
Have you received your second vaccine dose? 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.
