Name *

First Name

Last Name

Date *

MM

DD

YYYY

Phone *

(###)

###

####

Do you have a Fever? *

Yes

No

Do you have a Cough? *

Yes

No

Do you have Shortness of Breath/Difficulty Breathing? *

Yes

No

Do you have a Sore Throat? *

Yes

No

Do you have Chills? *

Yes

No

Is it Painful to Swallow? *

Yes

No

Do you have a Runny Nose / Nasal Congestion? *

Yes

No

Do you Feel Unwell / Fatigued? *

Yes

No

Do you have Nausea / Vomiting / Diarrhea *

Yes

No

Do you have an Unexplained Loss of Appetite? *

Yes

No

Have you Lost your Sense of Taste or Smell *

Yes

No

Do you have Muscle / Joint Aches? *

Yes

No

Do you have a Headache? *

Yes

No

Do you Conjunctivitis (commonly known as pink eye)? *

Yes

No

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

Yes

No

Have you had close contact with a confirmed case of COVID-19 in the last 14 days? *

A close contact is one with whom you have had face-to-face contact within 2 metres. A health care worker in an occupational setting wearing the recommended personal protective equipment is not considered to be a close contact.

Yes

No

Have you had close contact with a symptomatic close contact of a confirmed case of COVID-19 in the last 14 days? *

Ill / Symptomatic means someone with COVID-19 symptoms on the list above.

Yes

No