Who is completing this form?
*
Paul Moore
Evelyn Oliver
Brenda McCrae
Jim Thornton
Megan Moore
Amanda Thornton
Marie Lefebvre
Joan Maiorano
Mikaela Gerber
Please check all of the symptoms you are experiencing that are
NEW or WORSENING:
Fever or chills
Difficulty breathing or shortness of breath
Cough
Sore throat or trouble swallowing
Runny/stuffy nose or nasal congestion
Decrease or loss of smell or taste
Nausea, vomiting, diarrhea or abdominal pain
Not feeling well, extreme tiredness or sore muscles
None
Have you travelled outside of Canada in the past14 days?
Yes
No
Have you had close contact with a confirmed or probable case of COVID-19?
Yes
No
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