Today's Date* MM slash DD slash YYYY Name* First Last Phone*Email* Do you have a risk factor for COVID-19 exposure the last 14 days?Returned from travel outside of Canada?* Yes No Been in close contact with anyone diagnosed with lab-confirmed COVID-19?* Yes No Lived or worked in a setting that is part of a COVID-19 outbreak?* Yes No Been advised to self-isolate or quarantine at home by public health?* Yes No Do you, or anyone in your household, have a NEW onset of COVID-like symptoms?Fever* Yes No Cough* Yes No Shortness of Breath* Yes No Diarrhea* Yes No Nausea and/or vomiting* Yes No Headache* Yes No Runny nose/nasal congestion* Yes No Sore throat or painful swallowing* Yes No Loss of sense of smell* Yes No Loss of appetite* Yes No Chills* Yes No Muscle aches* Yes No Fatigue* Yes No NameThis field is for validation purposes and should be left unchanged. Δ
