COVID-19 Screening Questionaire

COVID-19 Screening Questionnaire

Name

full name

Your Email

1. Did you or anyone in your family travel outside of Canada in the past 14 days?

select one

Yes

No

2. If you answered yes, where did you go and when did you return? If you didn't travel please write N/A

3. Have you quarantined for 14 days upon your return?

select one

Yes

No

N/A

4. Have you or anyone in your family been sick or tested positive for COVID-19 or had close contact with a someone else who is sick or is a suspected or confirmed case of COVID-19?

select one

Yes

No

5. Do you have any of the following symptoms now or in the last 14 days?

select one