COVID-19 SCREENING FORM

Fever or chills

Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher *

Cough or barking cough (croup)

Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have *

Shortness of breath

Not related to asthma or other known causes or conditions you already have *

Sore throat

Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have *

Difficulty swallowing

Painful swallowing (not related to other known causes or conditions you already have) *

Decrease or loss of smell or taste

Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have *

Pink eye

Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have) *

Runny or stuffy/congested nose

Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have *

Headache

Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have) Note: If you received a COVID-19 vaccination in the last 48 hours and are experiencing a mild headache that only began after vaccination, select “No.” *

Digestive issues like nausea/vomiting, diarrhea, stomach pain

Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have *

Muscle aches/joint pain

Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have) Note: If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild muscle aches/joint pain that only began after vaccination, select “No.” *

Falling down often

For older people *

Fatigue

Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)Note: If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select “No.” *

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

This can be because of an outbreak or contact tracing *

3. In the last 10 days, have you tested positive on a rapid antigen test or a homebased self-testing kit?

If you have since tested negative on a lab-based PCR test, select “No.” *

4. In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?

If public health has advised you that you do not need to self-isolate (e.g., you are fully vaccinated† or another reason), select “No. *

5. In the last 14 days, have you received a COVID Alert exposure notification on your cell?

If you are fully vaccinated‡ or have already gone for a test and got a negative result, select "No." *

6. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?

*

7. In the last 14 days, has someone in your household (someone you live with):

• travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements; OR
• 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?

If you are fully vaccinated, select “No.” *

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

If you are fully vaccinated, select “No.” *