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

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