COVID-19 SCREENING FORM

To ensure the safety of our staff and customers, please fill out the following COVID screening form upon entering our facilities.

COVID Tracking Form 2
I am a *

1. Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions.

Choose any/all that are new, worsening, and not related to other known causes or medical conditions.

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.” *

9. I am following the Covid-19 guidelines and regulations as outlined by the Government and Provincial Law?

*