COVID Screening Form
To further limit the potential transmission of Coronavirus (COVID-19) and other illnesses, please answer the following questions:
Date
-
Day
-
Month
Year
Date
Full Name
*
First Name
Last Name
E-mail
*
Phone Number
*
-
Area Code
Phone Number
Are you currently experiencing any of these symptoms?
*
Fever and/or Chills
Decrease or Loss of taste or smell
Tiredness/Fatigue
Sore Throat
Runny nose/Nasal congestion
Headache
Nausea/Vomiting/Diarrhea
Cough/Shortness of Breath/Difficulty breathing
Muscle aches/Joint pain
None of The Above
Other
In the last 14 days, have you travelled outside of Canada (including USA)?
*
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
Have you been in close contact with someone with any new symptoms (like a cough, fever, or difficulty breathing) in the last 14 days?
*
Yes
No
In the last 10 days have you, or anyone you know, tested positive for COVID-19?
*
Yes
No
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