All Items must be filled out before this form can be submitted.

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Customer Contact Information<\/h4><\/div>
First Name<\/label><\/div>
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Last Name<\/label><\/div>
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Phone Number<\/label><\/div>
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Email address<\/label><\/div>
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Service Call Date<\/label><\/div>
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Travel Information<\/h4><\/div>
Did you or any member of your household travel outside of Ontario in the past 14 days?<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div>
Did you or any member of your household have a confirmed case of COVID-19, or contact with anyone that has?<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div>
Symptom Information - Are you or any member of your household experiencing any of the following symptoms?<\/h4><\/div>
Fever<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div>
Shortness of breath<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div>
Difficulty swallowing<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div>
Headaches<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div>
Pink eye<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div>
New onset of cough<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div>
Difficulty breathing<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div>
Decrease of loss of sense of taste or smell<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div>
Unexplained fatigue\/malaise\/muscle aches<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div>
Worsening chronic cough<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div>
Sore throat<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div>
Chills<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div>
Nausea\/vomiting, diarrhea, abdominal pain<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div>
Runny nose or nasal congestion without known cause<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div>
Age Information<\/h4><\/div>
Are you or any member for your household 70 years old or older?<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div>
Is any member of your household older than 70 experiencing any of the following symptoms?<\/h4><\/div>
Delirium<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div>
Acute functional decline<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div>
Unexplained or increased number of falls<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div>
Worsening of chronic conditions<\/label><\/div>
Yes<\/span><\/label><\/div>
No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div>
Submit Report<\/h4>
By submitting this form you are confirming that to the best of your knowledge all of the information provided is correct.\n\nThank you for helping us protect one another from COVID-19.<\/p><\/div>
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