Daily Health Screener
Name
*
First Name
Last Name
E-Mail
*
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Minutes
Are you currently experiencing any of these issues?
*
Severe difficulty breathing. (Struggling for each breath, can only speak in single words)
Severe chest pain. (Constant tightness crushing sensation)
Feeling confused or unsure of where you are.
Losing consciousness.
None of above.
Are you experiencing any of these signs or symptoms? Choose any/all that are new, worsening, and not related to other know causes or conditions.
*
Fever of 37.8ºC/100ºF or higher
Cough that's new or worsening. (Continuous, more than usual, not related to other known causes or conditions eg. COPD)
Barking cough, making a whistling noise when breathing. (Not related to other known causes or conditions)
Shortness of breath. (Out of breath, unable to breathe deeply, not related to other know causes or conditions eg. asthma)
Sore throat. (Related to other know causes or conditions eg. allergies, acid reflux)
Difficulty swallowing. (Painful swallowing not related to other known causes or conditions)
Stuffy or congested nose. (Not related too to other known causes or conditions)
Runny nose. (Not related to other known causes or conditions eg. seasonal allergies, cold weather)
Decrease or loss of taste or smell. (Not related to other known causes or conditions eg, Neurological disorders, allergies)
Pink eye. (Conjunctivitis, not related to other known causes or conditions eg. recurring styes)
Headache that's unusual or long lasting. (Not related to other known causes or conditions eg. tension headaches, chronic migraines)
Digestive issues like nausea/vomiting, diarrhea, stomach pain. (Not related to other known causes or conditions eg. anxiety, menstrual cramps, IBS)
Muscle aches that are unusual or long-lasting. (Not related to other known causes or conditions eg. sudden injury, fibromyalgia)
Extreme tiredness that is unusual, fatigue, lack of energy. (Not related to other known causes or conditions eg. depression, insomnia, thyroid disfunction)
Falling down often. (For older people)
None of the above.
Have you travelled anywhere outside of Canada in the last 10 days?
*
Yes
No
Have you been exempt from quarantining by Public Health / government officials?
*
Yes
No
Are you living with anyone who is currently positive for COVID-19 in the last 10 days?
*
Yes
No
Have you had any known exposure in the last 10 days?
*
Yes
No
Have you been in contact with anyone who has traveled outside the country in the last 10 days?
*
Yes
No
Are you fully vaccinated?
*
Yes
No
When was your last COVID test?
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Month
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Day
Year
Date
What was the result?
*
Positive
Negative
Cleared?
✅
❌
NOT Cleared
❌
Submit
Should be Empty: