COVID-19 Screening Form

COVID-19 Screening Form
Name
Name
First Name
Last Name
Have you travelled outside of Canada in the last 14 days?
Has someone you are in close contact with tested positive for COVID-19in the last 14 days?
Are you in close contact with a person who is sick with new respiratory symptoms or who recently traveled outside of Canada?
Do you have a fever? (temperature ≥ 37.8 °C)
Do you have any of these symptoms?
Chills?
New or worsening cough (dry or productive)?
Barking cough (croup)?
Shortness of breath/difficulty breathing?
Sore throat?
Difficulty swallowing?
Loss of taste or smell?
Pink eye (conjunctivitis)?
Headache that is unusual or long-lasting?
Runny or stuff nose (not related to seasonal allergies or other known causes or conditions)?
Nausea/vomiting/diarrhea/abdominal pain?
Muscle aches?
Unexplained fatigue/malaise?
Falling more than usual?
If you have answered:
Are these symptoms typical for you (i.e. history of allergies, migraines, other known medical condition that usually causes these symptoms)?