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Covid Pre-Screen Form

Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions.

• fever or chills (temperature of 37.8°C/100°F or higher)
• shortness of breath (not related to asthma or other known causes or conditions you already have)
• cough or barking cough (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)
• decrease or loss of smell or taste (not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have)
• fatigue, lethargy, malaise (unusual tiredness, lack of energy not related to known causes) If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select, NO.

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select NO. If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select NO

In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?

In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19? (If public health has advised you that you do not need to self-isolate, e.g. you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select NO)

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing.

In the last 10 days, have you received a COVID Alert exposure notification on your cell phone? (If you already went for a test and got a negative result, or if you are fully immunized, or have tested positive for COVID-19 in the last 90 days and since been cleared, select NO)

In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? (If you have since tested negative on a lab-based PCR test, select “NO”)