COVID-19
Screening Form
Visitor Name
Purpose of Visit
Phone Number
Have you travelled outside of Canada in the last 14 days?
Yes
No
Have you been in close contact with anyone who tested positive of COVID-19?
Yes
No
Do you have any of the following symptions?
Fever
New onset of cough
Worsening chronic cough
Difficulty breathing
Sore throat or hoarse Voice
Difficulty swallowing
Decrease or loss of sense of taste or smell
Headaches
Unexplained fatigue or muscle aches
Abdominal pain
Nausea or vomiting
Pink eye (conjunctivitis)
Runny nose
Nasal congestion without other known cause
Submit Form