COVID-19 Screening Form Name(Required) First Last Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201. A) Do you or anyone in your household have 1 or more of these new or worsening symptoms today or in the last 5 or 10 days?(Required)Check all that apply. Fever over 37.8°C and/or chills Cough Difficulty breathing Decrease of loss of taste/smell No Symptoms You and your household members should self-isolate.1. B) Do you or anyone in your household have 2 or more of these new or worsening symptoms today or in the last 5 or 10 days?(Required)Check all that apply. If the symptom is from a known health condition that gives you/them the symptom, DO NOT check the box. If the symptom is new, different or getting worse, DO check the box. If there is mild tiredness, sore muscles or joints within 48 hours after a COVID-19 vaccine, DO NOT check the box. Anyone who is sick or has any symptoms of illness, should stay home and seek assessment from their health care provider if needed. If you have one symptom from Part B, stay home until symptoms improve for at least 24 hours or 48 hours if nausea/vomiting/diarrhea. Sore throat Headache Feeling very tired Runny nose/nasal congestion Muscle aches/joint pain Nausea, vomiting or diarrhea No Symptoms If you have one new or worsening symptom from Question 1. B), stay home until symptoms improve for at least 24 hours or 48 hours in the case of nausea/vomiting/diarrhea.If you clicked on TWO OR MORE new or worsening symptoms in Question 1. B), you and your household members should self-isolate.2. Have you or anyone in the household had a positive COVID-19 test in the last 5 or 10 days*, or been told to stay home and self-isolate?(Required) Yes No If you had a positive test or live with someone who is isolating or awaiting test results select “Yes”You and your household members should self-isolate.3. In the last 14 days, have you travelled outside of Canada?(Required) Yes No Follow federal quarantine travel rules including required measures for quarantine exempt travellers.