Daily COVID-19 Screening

26/10/2021
Name

1. Do you have any of the following  new or worsening  symptoms or signs? Symptoms should NOT be chronic or NOT related to having received the COVID-19 vaccine in the past 48 hours or NOT related to other known causes or medical conditions – some examples of other known causes or conditions are provided below.

Fever and/or chills (temperature of 37.8C / 100F or higher):
Difficulty breathing or shortness of breath (e.g. NOT asthma):
Cough or barking cough (croup) (e.g. NOT asthma, post-infectious reactive airways, COPD):
Sore throat, trouble swallowing (e.g. NOT seasonal allergies, acid reflux):
Runny or stuffy/congested nose (e.g. NOT seasonal allergies, being outside in cold weather):
Decrease or loss of smell or taste (e.g. NOT allergies, neurological disorders):
Headache that is unusual or long lasting (e.g. NOT tension-type headaches or chronic migraines):
Pink eye (e.g. NOT recurring styes):
Nausea, vomiting, diarrhea, abdominal pain (e.g. NOT irritable bowel syndrome, menstrual cramps):
Not feeling well, extreme tiredness, or muscle aches that are unusual or long lasting (e.g. NOT depression, insomnia, thyroid dysfunction, fibromyalgia, sudden injury):
Falling down often (for older people):
2. Have you OR anyone you live with travelled outside of Canada in the past 14 days? (If you are fully vaccinated (you received the second dose at least 14 days ago), answer “No.”  If you were advised to quarantine by Government Officials, answer “Yes”.  If you are a truck driver / essential worker who crosses the Canada-US border regularly for work, answer “No”)
3. In the last 14 days, have you had close contact with a confirmed or probable case of COVID-19? (If you are fully vaccinated (you received the second dose at least 14 days ago), answer “No.”  If you were advised to quarantine by a Public Health Officer, answer “Yes”)
4. Is anyone in your household currently experiencing any new COVID-19 symptoms (not related to them receiving the vaccine within the past 48 hours) and/or waiting for test results after experiencing symptoms OR have you received a COVID Alert App notification on your cell phone?  (If you are fully vaccinated (you received the second dose at least 14 days ago), answer “No.” )