COVID-19 Screening Questionnaire

Name*

First Last

Email*

Phone*

1.

Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.

Fever or chills*

Yes
No

Difficulty breathing or shortness of breath*

Yes
No

Cough*

Yes
No

Sore throat, trouble swallowing*

Yes
No

Runny nose/stuffy nose or nasal congestion*

Yes
No

Decrease or loss of smell or taste*

Yes
No

Nausea, vomiting, diarrhea, abdominal pain*

Yes
No

Not feeling well, extreme tiredness, sore muscles*

Yes
No

2.

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

Yes
No

3.

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

Yes
No

Name

This field is for validation purposes and should be left unchanged.