Name *

First Name

Last Name

Date *

MM

DD

YYYY

Are you currently experiencing any of the following symptoms (check all that apply): *

Fever and/or chills (Temperature of 37.8 C or higher)

Cough or barking cough (continuous, more than usual, making a whistling noise when breathing, not related to asthma, COPD or other known conditions you already have)

Shortness of breath (out of breath, unable to breath deeply, not related to asthma, COPD or other known conditions you already have)

Decrease of loss of taste or smell (not related to seasonal allergies, neurological disorders or other known conditions you already have)

Muscle aches/joint pain (unusual, long lasting, not related to a sudden injury, fibromyalgia, or other known conditions you already have)

Extreme tiredness (unusual fatigue, lack of energy, not related to depression, insomnia, thyroid dysfunction or other known conditions you already have)

None of the above

In the last 14 days, have you travelled outside of Canada and been told to quarantine (per the federal quarantine requirements)? *

Yes

No

Has a doctor, health care provider or public health unit told you that you should currently be isolating (staying at home either due to an outbreak or contact tracing)? *

Yes

No

In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit (if you have since tested negative on a lab-based PCR test, select "no")? *

Yes

No