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
N/A - I am not/was not feeling sick
Fever
Cough
New onset of cough
Worsening chronic cough
Shortness of breath
Difficulty breathing
Sore throat
Difficulty swallowing
Decrease of loss of sense of taste or smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose or nasal congestion without other known cause
submit