Name *

First Name

Last Name

Phone *

(###)

###

####

Do you have any new onset (or worsening) of any of the following: *

Checking the box=YES

Fever

Cough

Shortness of Breath/Difficulty Breathing

Sore Throat

Chills

Painful swallowing

Runny nose/nasal congestion

Feeling unwell/fatigued

Nausea/Vomiting/Diarrhea

Unexplained Loss of Appetite

Loss of sense of taste or smell

Muscle/joint aches

Headache

Conjunctivitis (pink eye)

NONE OF THE ABOVE

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? *

Face-to-face contact within 2 metres. A health care worker in a 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 case 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