Today's Date* Date Format: MM slash DD slash YYYY Name* First Last Phone*Email* Do you have a risk factor for COVID-19 exposure the last 14 days?Returned from travel outside of Canada?*YesNoBeen in close contact with anyone diagnosed with lab-confirmed COVID-19?*YesNoLived or worked in a setting that is part of a COVID-19 outbreak?*YesNoBeen advised to self-isolate or quarantine at home by public health?*YesNoDo you, or anyone in your household, have a NEW onset of COVID-like symptoms?Fever*YesNoCough*YesNoShortness of Breath*YesNoDiarrhea*YesNoNausea and/or vomiting*YesNoHeadache*YesNoRunny nose/nasal congestion*YesNoSore throat or painful swallowing*YesNoLoss of sense of smell*YesNoLoss of appetite*YesNoChills*YesNoMuscle aches*YesNoFatigue*YesNoEmailThis field is for validation purposes and should be left unchanged.