COVID-19 Pre-Screening Form

Fever and/or chills

Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or
higher and/or chills

Cough or barking cough (croup)

Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, or other known causes or conditions they already have)

Shortness of breath

Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions they already have)

Decrease or loss of taste or smell

Not related to seasonal allergies, neurological disorders, or other known causes or conditions they already have

Nausea, vomiting and/or diarrhea

Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions they already have

Runny Nose / Nasal Congestion

Extreme Fatigue

Muscle Aches / Joint Pain

Headache

Sore Throat

2. Is someone that you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

Children (<18 years old): fever and/or chills, cough or barking cough, shortness of breath, decrease or loss of taste or smell, nausea, vomiting and/or diarrhea
Adults: (≥18 years old): fever and/or chills, cough or barking cough, shortness of breath, decrease or loss of taste or smell, tiredness, muscle aches

If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing only mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”

3. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?

If public health has advised you that you do not need to self-isolate, select “No.”

4. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?

If you have since tested negative on a lab-based PCR test, select “No.”

5. Do any of the following apply?

• In the last 14 days, you travelled outside of Canada and were told to quarantine
• In the last 14 days, you travelled outside of Canada and were told to not attend school/child care
Please note that if your are not fully vaccinated but are exempt from federal quarantine because you travelled with a vaccinated companion, you must not attend school or child care for 14 days. Select “yes” if this applies to the you.

7. In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit?

If you have since tested negative on a lab-based PCR test, select “No.”