COVID-19 Yonge & Eglinton FormPlease enable JavaScript in your browser to complete this form. - Step 1 of 3Do you have Two (2) or more of the following symptoms?Sore throatHoarse voiceDifficulty swallowingDecreased or loss of sense of taste or smellChillsHeadachesUnexplained fatigue/malaiseDiarrheaAbdominal painNausea/vomitingPink eye (conjuctivitis)Runny nose/sneezing without other known causeNasal congestion without other known causePlease select which best applies to youNextAre you presenting with a fever, new onset of cough, worsening chronic cough, shortness of breath or difficulty breathing? *YesNoDid you have close contact with anyone with acute respiratory illness? *YesNoHave you travelled outside Canada within the last 14 days? *YesNoDo you have a confirmed case of COVID-19 or have had contact with a confirmed case of COVID-19? *YesNoIf you are 65 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline or worsening of chronic conditions? *YesNoNextFailure to disclose full medical information may result in complications *I certify that all medical information provided is trueName *FirstLastDate *PhoneSubmit