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COVID-19 pre-screening form

COVID-19 pre-screening form

Yes No



Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

Yes No

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

Yes No

Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)

Yes No

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

Yes No

Unusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)

Yes No

Unusual fatigue, lack of energy (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)

Yes No

Painful or difficulty swallowing (not related to post-nasal drip, acid reflux, or other known causes or conditions you already have)

Yes No

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

Yes No

New, unusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, tension-type headaches, chronic migraines, or other known causes or conditions you already have)

Yes No

Not related to irritable bowel syndrome, anxiety, menstrual cramps, medication side effects, or other known causes or conditions you already have

Yes No



Yes No

This can be because of an outbreak or contact tracing.

Yes No

This includes a positive COVID-19 test result on a lab-based PCR test, rapid molecular test, rapid antigen test, or home-based self-testing kit.

Yes No

  • You live with someone who is currently isolating because of a positive COVID-19 test
  • You live with someone who is currently isolating because of COVID-19 symptoms
  • You live with someone who is isolating while waiting for COVID-19 test results

Select “No” if:

  • you are 18 or older and have received your booster, and/or
  • you are 17 or younger and are fully vaccinated, and/or
  • you completed your isolation after testing positive in the last 90 days (using a rapid antigen, rapid molecular, or PCR test), and/or
  • your household member is isolating because of COVID-19 symptoms but has already tested negative on one PCR or rapid molecular test, or two rapid antigen tests

Yes No




Thanks for submitting the form, you have passed

Thanks for submitting the form, you have not passed.