First Name: Last Name: Email: Phone Number
1. In the last 14 days, have you had close physical contact with someone who tested positive for COVID-19? This includes receiving a COVID Alert exposure notification.
Close physical contact means a) being less than 2 metres away in the same room, workspace, or area b) living in the same home.
YesNo
2. Have you travelled outside of Canada in the last 14 days?
3. Do you have any of the following symptoms? Select symptoms that are new, worsening and not related to other known causes or conditions.
FeverNew onset of coughWorsening chronic coughShortness of breathDifficulty breathingSore throatDifficulty swallowingDecrease or loss of sense of taste or smellChillsHeadachesUnexplained fatigue/malaise/muscle aches (myalgias)Nausea/vomiting, diarrhea, abdominal painPink eye (conjunctivitis)Runny nose/nasal congestion without other known causeFeeling confused or unsure where you areFalling down often