COVID-19 Screening Form

Your Name *

Your Telephone Number *

Reason for your visit *

Date of Visit *

Please read the following questions. If you answer YES to ANY of the questions, you cannot enter our workplace at this time, and should contact your healthcare provider or Telehealth Ontario at 1-866-797-0000 for further assistance.

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

Fever and/or chills	Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
Cough or barking cough (croup)	Not related to asthma, post-infectious reactive airways, COPD or other known causes or conditions you already have
Shortness of breath	Not related to asthma or other known causes or conditions you already have
Sore throat	Not related to seasonal allergies, acid reflux or other known causes or conditions you already have
Difficulty swallowing	Painful swallowing not related to 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
Pink eye	Conjunctivitis not related to recurring styes or other known causes or conditions you already have
Runny or stuffy/congested nose	Not related to seasonal allergies, being outside in the cold weather, or other known causes or conditions you already have
Headache	Unusual, long-lasting not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have
Digestive issues like nausea/vomiting, diarrhea, stomach pain	Not related to irritable bowel syndrome, menstrual cramps or other known causes or conditions you already have
Muscle Aches	Unusual, long lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have)
Extreme tiredness	Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)
Falling down often	For older people

2. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *YesNo

3. In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19? *YesNo

4. In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? *YesNo

5. In the last 14 days, have you travelled outside of Canada? *YesNoIf you are exempted from federal quarantine as per Group Exemptions, Quarantine Requirements under the Quarantine Act, select No.

If any of the answers to these screening questions change during the day, you should inform us of the change and go home to self-isolate immediately and contact you health care provider or Telehealth Ontario (1 866-797-0000) to get advice or an assessment, including if you need a COVID-19 test.

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