COVID-19 questionnaire
Please complete the form below.
Are you currently experiencing any of these symptoms? (Check all that apply).
Fever
(37.8 degrees Celcius or higher)
Chills
Cough that's new or worsening
(ccontinuous, more than usual)
Barking cough, making a whistling noise when breathing
(croup)
Shortness of breath
(out of breath, unable to breathe deeply)
Sore throat
Difficulty swallowing
Runny nose
(not related to seasonal allergies or other known causes or conditions)
Stuffy or congested nose
(not related to seasonal allergies or other known causes or conditions)
Lost sense of taste or smell
Pink eye
(conjunctivitis)
Headache that is unusual or long lasting
Digestive issues
(nausea/vomiting, diarrhea, stomach pain)
Muscle aches
Extreme tiredness that is unusual
(fatigue, lack of energy)
Falling down often
For young children and infants: sluggishness or lack of appetite
In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19?
In the last 14 days, have you been in close physical contact with a person who is currently sick with a new cough, fever, or difficulty breathing?
In the last 14 days, have you been in close physical contact with a person who returned from outside of Canada in the last 2 weeks?
Have you travelled outside of Canada in the last 14 days?
None of the above