Firstname		Lastname
Street Address
Address Line 2
City		Province	Ontario
Postal Code		Phone Number
Email Address

PATIENT QUESTIONNAIRE
1.	Have you traveled anywhere recently in the past 14 days?	Yes No
2.	Have you been in contact with anyone who was sick or diagnosed with COVID-19, or who was in contact with anyone who was sick or diagnosed with COVID-19 in the past 14 days?	Yes No
3.	Have you attended any large group functions in the past 14 days?	Yes No
4.	Have you had any of the following symptoms within the last two weeks: fever, fatigue, dry cough, altered taste, altered smell, trouble breathing, productive cough (mucous in cough), or muscle pain?	Yes No
5.	Have you previously had the SARS-COV-2 virus (novel coronavirus)? Did you test positive?	Yes No
6.	Are you over the age of 65?	Yes No
7.	Do you have any pre-existing health conditions related to any of the following
Diabetes Chronic Lung Disease Asthma Serious Heart Condition Immunocompromised Chronic Kidney Liver Disease