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. Do you have any of the following new or worsening symptoms or signs? 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)

Continuous, more than usual, making a whistling noise when breathing, not related to other known causes or conditions (for example, asthma, post-infectious reactive airways, COPD) *

Shortness of breath

Out of breath, unable to breathe deeply, not related to other known causes or conditions (for example, asthma) *

Decrease or loss of smell or taste

Not related to other known causes or conditions (for example, allergies, neurological disorders) *

Sore throat

Not related to other known causes or conditions (for example, seasonal allergies, acid reflux) *

Difficulty swallowing

Painful swallowing, not related to other known causes or conditions *

Pink eye

Conjunctivitis, not related to other known causes or conditions (for example, reoccurring styes) *

Runny or stuffy/congested nose

Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather) *

Headache that’s unusual or long lasting

Not related to other known causes or conditions (for example, tension-type headaches, chronic migraines) *

Digestive issues like nausea/vomiting, diarrhea, stomach pain

Not related to other known causes or conditions (for example, irritable bowel syndrome, menstrual cramps) *

Muscle aches that are unusual or long lasting

Not related to other known causes or conditions (for example, a sudden injury, fibromyalgia) *

Extreme tiredness that is unusual

Fatigue, lack of energy, not related to other known causes or conditions (for example, depression, insomnia, thyroid dysfunction) *

Falling down often

For older people *

2. Have you travelled outside of Canada in the last 14 days?

If you are an essential worker who crosses the Canada-US border regularly for work, select “No”. *

3. In the last 14 days, has a public health unit identified you as a close contact of someone who currently has COVID-19?

*

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

*

5. In the last 14 days, have you received a COVID Alert exposure notification on your cell? If you already went for a test and got a negative result, select “No.”

*

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

*