Covid-19 Screen Form Name* Contact (Phone Number or Email)* Date* MM slash DD slash YYYY Location to be Accessed Do you have any of the following new or worsening symptoms or signs?Symptoms should not be chronic or related to other well known causes or conditions. Fever or Chills?* Yes No Difficulty breathing or shortness of breath?* Yes No Cough?* Yes No Sore throat, trouble swallowing?* Yes No Runny nose, Stuffy nose or nasal congestion?* Yes No Decrease in loss of smell or taste?* Yes No Nausea, vomiting, diarrhea, abdominal pain?** Yes No Not feeling well, extreme tiredness, sore muscles?* Yes No Have you traveled outside of Canada in the past 14 days?* Yes No Have you had close contact with a confirmed or probable case of COVID-19?* Yes No EmailThis field is for validation purposes and should be left unchanged.