8290 Highway 27, Unit 4 | Woodbridge, ON L4H0S1 (289) 236-0206

COVID-19 Screening Form

COVID-19 Screening

Have you travelled outside of Canada in the past 14 days?

Have you tested positive to COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

Do you have any of the following symptoms: Fever • Cough • Worsening cough • Shortness of breath • Difficulty breathing • Sore throat • Difficulty swallowing • Decreased or loss of sense of taste or smell • Chills • Headaches • Unexplained fatigue/malaise/muscle aches • Nausea/vomiting, diarrhea, abdominal pain • Pink eye • Runny nose/nasal congestion with unknown cause

If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions?