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Name:

Email:

Best Contact Number:

Do you have a fever (37.5 degrees Celsius or higher) or have felt hot or feverish anytime in the last two weeks?
YesNo

Do you have a dry cough?
YesNo

Do you have shortness of breath?
YesNo

Do you have difficulty breathing?
YesNo

Do you have a runny nose?
YesNo

Are you sneezing?
YesNo

Do you have a sore throat?
YesNo

Do you have post-nasal drip?
YesNo

Have you experienced a recent loss of smell or taste?
YesNo

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?
YesNo

Have you returned from travel outside of Canada in the last 14 days?
YesNo

Have you returned from travel within Canada from a location known affected with COVID-19?
YesNo

Is your workplace considered high risk?
YesNo

Do you have any of the following: heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder?
YesNo

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