Covid Screening - Delmo Molds

Your Information

Date of Submission

Full Name

Required Screening Questions

1. Are you currently experiencing one or more of the symptoms below that are new or worsening?

Symptoms should not be chronic or related to other known causes or conditions.

Fever and/or chills

Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

Cough or barking cough (croup)

Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have

Shortness of breath

Not related to asthma or other known causes or conditions you already have

Decrease or loss of smell or taste

Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

(For adults >18 years or older) Fatigue, lethargy, malaise and/or myalgias

Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have). If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select "No"

(For children <18 years) Nausea, vomiting and/or diarrhea

Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have

Yes, I am experiencing one or more of these symptons.

None of the above

2. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?

Yes No

3. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

Yes No This can be bacuse of an outbreak or contact tracing

4. In the last 10 days, have you been indentified as a "close contact" of someone who currently has COVID-19?

Yes No If public health has advised you that you do not need to self-isolate (e.g., you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared), select "No"

5. In the last 10 days, have you recieved a COVID Alert exposure notifcation on your cellphone?

Yes No If you have already gone for a test and got a negative result, select "No." If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select "No."

6. In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit?

Yes No If you have since tested negative on a lab-based PCR test, select "No."

7. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

Yes No If the individual experiencing symptons received a COVID-19 vaccination in the last 48 hours and is experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select "No." If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select "No."

Covid-19 Screening Form

Your Information

Required Screening Questions