Name *

First Name

Last Name

Phone *

(###)

###

####

Do you have any of the following new or worsening symptoms or signs? Note: Symptoms should not be chronic or related to other known causes or conditions. *

• Fever or chills • Difficulty breathing or shortness of breath • Cough • Sore throat, trouble swallowing • Runny nose/stuffy nose or nasal congestion • Decrease or loss of smell or taste • Nausea, vomiting, diarrhea, abdominal pain • Not feeling well, extreme tiredness, sore muscles

No

Yes

Have travelled outside of Canada in the past 14 days? *

No

Yes

Have you had close contact with a confirmed or probable case of COVID-19? *

No

Yes