Covid 19 Assessment Form

Do you have one or more of the following symptoms?

Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higherCough or Barking - Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already haveShortness of breath - Not related to asthma or other known causes or conditions you already haveDecrease or loss of smell or taste - Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already haveNone of the Above
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Do you have one or more of the following symptoms?

Runny or stuffy/congested noseSore throatHeadacheMuscle aches/joint painFatigueNausea, vomiting and/or diarrheaNone of the Above
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In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)? YesNo
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Has a doctor, health care provider, or public health unit told you that you should
currently be isolating (staying at home)?YesNo
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In the last 10 days, have you tested positive for COVID-19?YesNo
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Do any of the following apply?
• You live with someone who is currently isolating because of a positive COVID19 test
• You live with someone who is currently isolating because of COVID-19 symptoms
• You live with someone who is waiting for COVID-19 test results
• If you tested positive for COVID-19 (on a lab-based PCR test, rapid antigen test, or home-based self-testing kit) on or after December 20, 2021 and have already completed your isolation period, select “No”.YesNo
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In the last 10 days, have you been identified as a “close contact” of someone who
currently has COVID-19 and doesn’t live with you?YesNo
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First Name

Last Name