COVID-19 Screening Questionnaire Have you tested positive for COVID-19?* Yes No Are you awaiting results for a COVID-19 test?* Yes No Do you have a fever over 38°C (100.4°F) or chills?* Yes No Do you have a new or worsening cough?* Yes No Do you have a sore throat?* Yes No Do you have a runny nose or nasal congestion that you wouldn't normally have because of seasonal allergies or another pre-existing condition?* Yes No Do you have other cold- or flu-like symptoms?* Yes No Are you having new or worsening shortness of breath or other difficulties breathing?* Yes No Have you experienced a recent loss of taste or smell?* Yes No Are you feeling tired or fatigued without explanation? Yes No Do you have a new or worsening headache?* Yes No Do you have nausea, vomiting, diarrhea, or abdominal pain?* Yes No Even if you do not currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?* Yes No In the past 14 days, have you been in close contact with any suspected or confirmed COVID-19 patients without personal protective equipment?* Yes No Do you have cardiovascular disease, lung disease (including moderate to severe asthma), kidney disease, or diabetes?* Yes No Are you immunocompromised?* Yes No Have you returned from travel outside Canada in the past 14 days?* Yes No Are you over 60 years of age?* Yes No Your Name* Your Phone Number* EmailThis field is for validation purposes and should be left unchanged.
