Screening

Your name *

Your email *

Phone Number *

Date completing the form *

Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.

Fever or chills *
YesNo

Difficulty breathing or shortness of breath *
YesNo

Cough *
YesNo

Sore Throat, trouble swallowing *
YesNo

Runny nose/stuffy nose or nasal congestion *
YesNo

Decrease or loss of smell or taste *
YesNo

Nausea, vomiting, diarrhea, abdominal pain *
YesNo

Not feeling well, extreme tiredness, sore muscles *
YesNo

Have you travelled outside of Canada in the past 14 days? *
YesNo

Have you had close contact with a confirmed or probable case of COVID-19? *
YesNo

In the past 14 days have been directed by Public Health to self-isolate? *
YesNo

Send me a copy of my responses