Patient InfoPatient Name* Patient Age* Screening QuestionsParent/Legal Guardian may fill out this section1. Do you have a fever (greater than 38°C) or feverish chills, sweats, muscle aches, light-headedness?* Yes No 2. Do you have any of these symptoms: New or worsening cough? Sore throat (difficulty swallowing)? New or worsening runny nose? New or worsening shortness of breath? New or worsening headache?* Yes No 3. Have you been in close personal contact, without PPE, with a suspected or confirmed COVID-19 patient within the past 2 weeks?* Yes No 4. Have you travelled outside of Atlantic Canada (Nova Scotia, New Brunswick, Prince Edward Island and Newfoundland and Labrador) by air, car, bus or otherwise in the past 2 weeks?* Yes No Patient VulnerabilityUseful in patient scheduling5. Do you have any of the following medical conditions which would put you in a high-risk category: Diabetes Cardiovascular Disease Hypertension Lung Diseases (including moderate to severe asthma) Immunocompromised Active Malignancy CAPTCHA