COVID-19 Screening Assessment

1. Are you currently experiencing any one of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.

Fever and/or chills
Cough or barking cough (croup)
Difficulty breathing or shortness of breath
Sore throat, difficulty swallowing
Decrease or loss of smell or taste
Pink eye
Runny or stuffy nose/congested nose
Headache
Digestive issues like nausea/vomiting, diarrhea, abdominal pain
Not feeling well, extreme tiredness, sore muscles
Falling down often (for older people)

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

3. In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?

4. In the last 14 days, have you received a COVID Alert exposure notification on your mobile phone?

5. In the last 14 days, have you travelled outside of Canada?

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

7. Please provide your full name: