Health Screening Questionnaire

Today's Date*

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?*

Been in close contact with anyone diagnosed with lab-confirmed COVID-19?*

Lived or worked in a setting that is part of a COVID-19 outbreak?*

Been advised to self-isolate or quarantine at home by public health?*

Fever*

Cough*

Shortness of Breath*

Diarrhea*

Nausea and/or vomiting*

Headache*

Runny nose/nasal congestion*

Sore throat or painful swallowing*

Loss of sense of smell*

Loss of appetite*

Chills*

Muscle aches*

Fatigue*

Email

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