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COVID-19 Screening Form
Name
*
First
Last
Date
*
Date Format: MM slash DD slash YYYY
COVID-19 Risk Factor Screening (please check all that apply)
I have had close contact with someone with acute respiratory illness in the past 14 days
I have a confirmed case of COVID-19 or have had close contact with a person with a confirmed case of COVID-19 without wearing the appropriate personal protective equipment (PPE)
I have travelled outside of Ontario in the past 14 days
COVID-19 Symptom Screening (please check all that apply to you or to any member of your household)
Fever
Chills
Cough that's new or worsening (continuous, more than usual)
Barking cough, making a whistling noise when breathing
Shortness of breath (out of breath, unable to breath deeply)
Sore throat
Difficulty swallowing
Runny, stuffy, congested nose (not related to seasonal allergies or other known causes or conditions)
Lost sense of taste or smell
Pink eye (conjunctivitis)
Headache that's unusual or long lasting
Digestive issues (nausea/vomiting, diarrhea, stomach pain)
Muscle aches
Extreme tiredness that's unusual (fatigue, lack of energy)
Falling down often
For young children and infants: sluggishness or lack of appetite
For households with someone 70 years of age or older (please check all that apply)
If you or someone in your household is 70 years of age or older, are you (they) experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions
I DO NOT have any COVID-19 symptoms or risk factors
If you (or members of your household) do not have any COVID-19 symptoms or risk factors please confirm this by checking the negative screening statement below.
NEGATIVE SCREENING STATEMENT
I confirm that I have reviewed the screening risk factors and symptoms carefully and none apply to me or members of my household.
