COVID-19 Questionnaire

Name *

First

Last

Email *

Do you have any new onset (or worsening) of any of the following symptoms: fever* (over 38o Celsius), cough*, shortness of breath/difficulty breathing*, runny nose* sore throat*, chills, painful swallowing, nasal congestion, feeling unwell / fatigued, nausea/vomiting/diarrhea, unexplained loss of appetite, loss of sense of taste or smell, muscle/joint aches, headache, conjunctivitis (pink eye)? *

Have you travelled outside of Canada in the last 14 days? *

Have you had close contact** with a confirmed case of COVID-19 in the last 14 days? *

Have you had close contact with an individual who has any one of the first 5 symptoms on this list (*) fever, cough, shortness of breath, runny nose or sore throat AND who is a close contact of a confirmed case of COVID-19 in the last 14 days? *