COVID-19 Screening Form

Name*

Contact (Phone Number or Email)*

Date*

Location to be Accessed*

Do you have any of the following new or worsening symptoms or signs?

Symptoms should not be chronic or related to other well known causes or conditions.

Fever or Chills?*

Difficulty breathing or shortness of breath?*

Cough?*

Sore throat, trouble swallowing?*

Runny nose, Stuffy nose or nasal congestion?*

Decrease in loss of smell or taste?*

Nausea, vomiting, diarrhea, abdominal pain?*

Not feeling well, extreme tiredness, sore muscles?*

Have you traveled outside of Canada in the past 14 days?*

Have you had close contact with a confirmed or probable case of COVID-19?*