Covid-19 Questionnaire

Do you have any of the following symptoms or signs?

• Severe difficulty breathing (struggling for each breath, can only speak in single words)
• Severe chest pain (constant tightness or crushing sensation)
• Feeling confused or unsure of where you are
• Losing consciousness
• Fever (feeling hot to the touch, a temperature of 37.8 degrees Celcuis or higher)
• Chills
• Cough that's new or worsening (continuous, 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's 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

In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19?

Close phyiscal contact means:

• being less than 2 meters away in the same room, workspace, or area for over 15 minutes
• living in the same home

In the last 14 days, have you been in close physical contact with a person who either:

• is currently sick with a new cough, fever or difficulty breathing?
• returned from outside of Canada in the last 2 weeks?

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