Covid-19 Questionnaire

Please Complete the form below

Covid-19 Health Declaration

How are you feeling today?

Full Name

I am not experiencing any of these symptoms in last 14 days: Cough, Fever and/or chills, Shortness of breath, Sore throat, Difficulty swallowing, Runny or Congested nose, Decrease or loss of taste or smell, Pink eye, Headache, Digestive Issues, Muscle aches, Extreme tiredness or flu-like symptoms.

I have not travelled outside of Canada in the last 14 days.

I have not been told by a doctor, health care provider, or public health unit that I should currently be isolating (staying at home).

I haven’t been in close contact with a Covid-19 patient in the last 14 days

I have not been told by a doctor, health care provider, or public health unit that I should currently be isolating (staying at home).

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!