Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Have you tested positive for COVID-19 or have you been advised by your physician or local health department to self isolate? *

Yes

No

Do you have one or more of the following - new or worsening symptoms? *

Please select all that apply.

Fever/Feeling hot or chills

Sore throat, difficulty swallowing

Shortness of breath or difficulty breathing

Cough or worsening of a chronic cough

Flu-like symptoms such as upset stomach, diarrhea, headache or fatigue

Recent alteration or loss of taste or smell

Any new, unusual symptoms such as malaise or sudden onset of runny nose

I have not experienced any of these symptoms

Have you been in contact with someone with probable or confirmed COVID-19? *

Yes

No

In those 70 years or older, are you experiencing any of the following? *

Please select all that apply.

Delirium, acute cognitive decline

Unexplained or increased number of falls

Worsening of chronic conditions

I have not experienced any of these symptoms

Have you traveled outside of Canada in the last 14 days? *

Yes

No