Required Screening Questions
Name
*
First Name
Last Name
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
1. Do you have any of the following new or worsening symptoms or signs?
Symptoms should be chronic or related to other known causes or conditions
Fever or Chills
Yes
No
Cough
Yes
No
Sore throat, trouble swallowing
Yes
No
Runny nose/stuffy nose or nasal congestion
Yes
No
Decrease or loss of smell or taste
Yes
No
Decrease or loss of smell or taste
Yes
No
Nausea, vomiting, diarrhea, abdominal pain
Yes
No
Not feeling well, extreme tiredness, sore muscles
Yes
No
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
Submit
Should be Empty: