Screening 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 - is your temperature 37.8 deg C or higher?

Yes

No

Cough or barking cough (croup)

Yes

No

Shortness of breath

Yes

No

Decrease or loss of smell or taste

Yes

No

Sore throat

Yes

No

Difficulty swallowing

Yes

No

Pink eye

Yes

No

Runny or stuffy/congested nose

Yes

No

Headache that’s unusual or long lasting

Yes

No

Digestive issues like nausea/vomiting, diarrhea, stomach pain

Yes

No

Muscle aches that are unusual or long lasting

Yes

No

Extreme tiredness that is unusual

Yes

No

Falling down often

Yes

No

Have you travelled outside of Canada in the past 14 days or been in contact with someone that has?

Yes

No

In the last 14 days, has a public health unit identified you as a close contact of someone who currently has COVID-19?

Yes

No

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

Yes

No

In the last 14 days, have you received a COVID Alert exposure notification on your cell? If you already went for a test and got a negative result, select “No.”

Yes

No

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

Yes

No

COVID Screening

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.

Have you travelled outside of Canada in the past 14 days or been in contact with someone that has?

In the last 14 days, has a public health unit identified you as a close contact of someone who currently has COVID-19?

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

In the last 14 days, have you received a COVID Alert exposure notification on your cell? If you already went for a test and got a negative result, select “No.”

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

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