Patient Name^*

Guardian Name^*

Screening Questions:

Patient

Guardian

1. Have you received your final (2 nd ) vaccination dose more than 14 days ago?
* A fully immunized individual is defined as any individual >14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series (i.e .Johnson and Johnson).

Yes No

Yes No

2. Do you have any of the following symptoms?

• Fever and/or chills
• New onset of cough or worsening chronic cough
• Shortness of breath
• Decrease or loss of sense of taste or smell
• For adult> 18 years of age: unexplained fatigue/lethargy/malaise/muscle aches
• For Child<18 years of age: nausea/vomiting, diarrhea

Yes No

Yes No

3. Have you tested positive in the last 10 days or have you been told to be isolating?

Yes No

Yes No

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

Yes No

Yes No

5. Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

Yes No

Yes No

Signature:^*

Date:^*