Covid 19 Screening Form EmailYour Information Date of Submission * Company Full Name * Phone Number * For individuals who are 18 years of age and older1. Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have. Fever and/or chills Fever and/or chills Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher Cough or barking cough (croup) Cough or barking cough (croup) Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have) Shortness of breath Shortness of breath Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have) Sore throat Sore throat Painful swallowing (not related to other known causes or conditions you already have) Difficulty swallowing Difficulty swallowing Painful swallowing (not related to other known causes or conditions you already have) Runny or stuffy/congested nose Runny or stuffy/congested nose Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have Decrease or loss of taste or smell Decrease or loss of taste or smell Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have Pink eye Pink eye Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have) Headache Headache Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have) Digestive issues like nausea/vomiting, diarrhea, stomach pain Digestive issues like nausea/vomiting, diarrhea, stomach pain Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have Muscles aches Muscle aches Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have) Extreme tiredness Extreme tiredness Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have) Falling down often Falling down often For older people None of the above None of the above 2. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? * Yes No 3. In the last 14 days, have you or anyone you live with travelled outside of Canada? * Yes No If exempt from quarantine requirements (for example, an essential worker who crosses the Canada-US border regularly for work), select “No.” 4. In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19? * Yes No 5. 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 because of an outbreak or contact tracing. 6. In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? * Yes No If you already went for a test and got a negative result, select “No.”
