COVID SELF-ASSESSMENT CHECKLIST
Please review the following FIVE (5) screening questions, and confirm via form submission below if you answer “YES” to one or more of the questions.
Are you experiencing any of the following symptoms:
Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)
Severe chest pain
Having a very hard time waking up
Feeling confused
Losing consciousness
Are you experiencing any of the following:
Mild to moderate shortness of breath
Inability to lie down because of difficulty breathing
Chronic health conditions that you are having difficulty managing because of difficulty breathing
Are you experiencing cold, flu or COVID-19-like symptoms, even mild ones? Symptoms include:
Fever*, chills, cough or worsening of chronic cough, shortness of breath, sore throat, runny nose, loss of sense of smell or taste, headache, fatigue, diarrhea, loss of appetite, nausea and vomiting, muscle aches.
While less common, symptoms can also include: stuffy nose, conjunctivitis (pink eye), dizziness, confusion, abdominal pain, skin rashes or discoloration of fingers or toes.
Have you travelled to any countries outside Canada (including the United States) within the last 14 days?
Did you provide care or have close contact with a person with confirmed COVID-19?
Screening Confirmation *
I answer "NO" to ALL of the above questions.
I answer "YES to ONE (1) or more of the above questions.