First Name *
Last Name
Phone Number *
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. *
No I do not.
Difficulty Breathing or Shortness of Breath
Cough
Sore Throat, Trouble Swallowing
Runny Nose/Stuffy Nose or Nasal Congestion
Decrease or Loss of Smell or Taste
Nausea, Vomiting, Diarrhea, Abdominal Pain
Not Feeling Well, Extreme Tiredness, Sore Muscles
Fever or Chills
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
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Covid-19 Screening
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