OHA COVID-19 Self-assessment

OHA COVID-19 Self-assessment
Name*

First NameLast Name
Email
example@example.com
Are you currently experiencing any of these issues? Call 911 if you are.
- Severe difficulty breathing (struggling for each breath, can only speak in single words)
- Severe chest pain (constant tightness or crushing sensation)
- Feeling confused or unsure of where you are
- Losing consciousness
YesNo
Are you currently experiencing any of these symptoms? Choose any/all that are new and not related to seasonal allergies or pre-existing medical conditions.*

Fever (feeling hot to the touch, a temperature of 37.8 degrees Celsius/100.4 degrees Fahrenheit or higher)ChillsCough that's new or worsening(continuous, more than usual)Barking cough, making a whistling noise when breathingShortness of breath (out of breath, unable to breathe deeply)Sore throat (not related to seasonal allergies or other known causes or conditionsDifficulty swallowingRunny nose (not related to seasonal allergies or other known causes or conditions)Stuffy or congested nose (not related to seasonal allergies or other known causes or conditions)Lost sense of taste or smellPink eye (conjunctivitis)Headache that’s unusual or long lastingDigestive issues like nausea/vomiting, diarrhea, stomach pain (not related to other known causes or conditions)Muscle aches that are unusual or long lastingExtreme tiredness that is unusual (fatigue, lack of energy)Falling downNone of the above
Are you in any of these at-risk groups?
- Getting treatment that compromises (weakens) your immune system
  (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors)
- Having a condition that compromises (weakens) your immune system
  (for example, lupus, rheumatoid arthritis, immunodeficiency disorder)
- Having a chronic (long-lasting) health condition
  (for example, diabetes, emphysema, asthma, heart condition, COPD)
- Regularly going to a hospital or health care setting for a treatment
  (for example, dialysis, surgery, cancer treatment)
YesNo
In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19?
Close physical contact means being less than 2 metres away in the same room, workspace, or area, or living in the same home.
YesNo
In the last 14 days, have you been in close physical contact with someone who either:
1. Is currently sick with new COVID-19 symptoms (like a cough, fever, or difficulty breathing)?
2. Has returned from outside of Canada in the last 2 weeks with new COVID-19 symptoms (like a cough, fever, or difficulty breathing)?
Close physical contact means being less than 2 metres away in the same room, workspace, or area, or living in the same home
YesNo
Have you travelled outside of Canada in the last 14 days?
This does not include essential workers who cross the Canada-US border regularly.
YesNo
Should be Empty: