Phone

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Name *

First Name

Last Name

Fever and/or chills *

Yes

No

Cough and/or barking cough *

Yes

No

Shortness of breath *

Yes

No

Decrease or loss of taste and/or smell *

Yes

No

Sore throat or trouble swallowing *

Yes

No

Runny or stuffy nose *

Yes

No

Abdominal pain that is persistent or ongoing (not related to known causes or conditions e.g., menstrual cramps, gastroesophageal feflux disease *

Yes

No

Headache that is unusual or long lasting *

Yes

No

Conjunctivitis (pink eye) *

Yes

No

A decreased or lack of appetite *

Yes

No

For Adults (18 years of age or older)

Tiredness, muscle aches or joint pain

Yes

No

Not Applicable

For Children (under 18 years of age)

Yes

No

Not Applicable

In the last 14 days, have you or someone you live with travelled outside of Canada AND been advised to quarantine (as per federal quarantine requirements)? *

Yes

No

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

Yes

No

In the last 10 days, have you been identified as a "close contact" of someone who currently has COVID-19? *

Yes

No

In the last 10 days, have you tested positive on a rapid antigen test or a home-based self testing kit? *

Yes

No

In the last 10 days, have you received a COVID alert exposure notification on your cell phone? *

Yes

No

In the last 10 days, has someone you live with been identified as a "close contact" of someone who currently has COVID-19 AND advised by a doctor, healthcare provider or public health unit to self-isolate? *

Yes

No

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

Yes

No