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123 Main Street

Do you have a new onset or any of the following symptoms?
- fever / chills
- cough
- sore throat / hoarse voice
- shortness of breath
- loss of taste or smell
- vomiting or diarrhea for more than 24 hours
- Runny nose
- Stuffy or congested nose
- Pink eye (Conjunctivitis)
- Headache that’s unusual or long lasting
- Muscle aches that are unusual or long lasting
- Extreme tiredness that is unusual
- skin rash of unknown cause
Yes No

Has a doctor, health care provider, or public health unit told you that you should be self-isolating (staying at home)?
Yes No

In the last 14 days, have you either:
- tested positive for COVID-19? Or
- been in close physical contact with someone who recently tested positive or currently sick with COVID-19? Or
- been in close physical contact with a person who has traveled outside Canada? Or
- received a notification from the COVID Alert app that you may have been exposed to COVID-19? Or
- travelled outside of Canada? or to areas within Canada which are required to self-isolate?
Close physical contact means:
- being less than 2 metres away in the same room,
- workspace, or area
- living in the same home
Yes No
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