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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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