Name *

First Name

Last Name

Date *

MM

DD

YYYY

Phone *

(###)

###

####

1. Fever/chills *

Yes

No

2. New cough or a cough that is worsening *

Yes

No

3. Difficulty Breathing *

Yes

No

4. Shortness of breath (even when sitting or walking regularly) *

Yes

No

5.Sore throat (not due to allergies) *

Yes

No

6. A runny or congested nose (not due to allergies) *

Yes

No

7. Unusual level of fatique *

Yes

No

8. Unusual headache *

Yes

No

9. Nausea/vomiting, diarrhea, or loss of appetite *

Yes

No

10. Feeling unwell for an unknown reason *

Yes

No

11. Lost sense of taste or smell *

Yes

No

12. Pink eye/conjunctivitis *

Yes

No

13. Muscle aches *

Yes

No

14. Falling down often *

Yes

No

15. Difficulty swallowing *

Yes

No

Have you been in close contact with someone who is either sick, sent for testing, or has confirmed COVID-19 in the past 14 days? *

Yes

No

If the answer is 'Yes' to the previous question: Are you fully vaccinated and not experiencing any symptoms? *

NOTE: An individual is defined as fully immunized 14 days after receiving their second dose of a two- dose COVID-19 Vaccine.

Yes

No

Have you returned from travel outside Canada in the past 14 days? *

Yes

No