Covid-19 Screen Form Name*Contact (Phone Number or Email)*Date* Location to be AccessedDo 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?*YesNoDifficulty breathing or shortness of breath?*YesNoCough?*YesNoSore throat, trouble swallowing?*YesNoRunny nose, Stuffy nose or nasal congestion?*YesNoDecrease in loss of smell or taste?*YesNoNausea, vomiting, diarrhea, abdominal pain?**YesNoNot feeling well, extreme tiredness, sore muscles?*YesNoHave you traveled outside of Canada in the past 14 days?*YesNoHave you had close contact with a confirmed or probable case of COVID-19?*YesNoEmailThis field is for validation purposes and should be left unchanged.