COVID SCREENING FORM

Date *

MM

DD

YYYY

Name *

First Name

Last Name

Phone

*Visitors Only

(###)

###

####

Have you received two doses of the COVID-19 vaccine?

Yes

No

Do you or anyone in your household have severe difficulty breathing, chest pain, confusion or loss of consciousness? *

Yes

No

Do you or anyone in your household have any of the following symptoms: *

- fever or chills - new or worsening cough, - shortness of breath, - sore throat, - difficulty swallowing, - stuffy or congested nose, - decrease or loss of taste or smell, - pink eye, - headache, - digestive issues like nausea/vomiting, diarrhoea, stomach pain, - muscle aches, - extreme tiredness that is unusual, - falling down often, - sluggishness or lack of appetite?

Yes

No

Have you travelled outside of Canada in the last 14 days? *

Yes

No

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

Yes

No

Have you been in close contact with a person with acute respiratory illness who has been to an impacted area for COVID-19 in the last 14 days? *

Yes

No