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COVID-19 pre-screening form
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COVID-19 pre-screening form

COVID-19 pre-screening form

Are you 18 years of age and older?

Yes No

Date

Name

Email

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.

Fever or chills

Yes No

Cough or barking cough (croup)

Yes No

Shortness of breath

Yes No

Decrease or loss of smell or taste

Yes No

Sore throat

Yes No

Sore throat or difficulty swallowing

Yes No

Difficulty swallowing

Yes No

Pink eye

Yes No

Runny or stuffy/congested nose

Yes No

Headache that’s unusual or long lasting

Yes No

Digestive issues like nausea/vomiting, diarrhea, stomach pain

Yes No

Nausea, vomiting and/or diarrhea

Yes No

Muscle aches that are unusual or long lasting

Yes No

Extreme tiredness that is unusual

Yes No

Falling down often

Yes No

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

Yes 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?

Yes No

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

Yes No

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.”

Yes No

Thanks for submitting the form, you have passed

Thanks for submitting the form, you have not passed.

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