Covid Screening Form

Do you currently have any of the following new or worsening symptoms? Symptoms should not be chronic or related to other known causes or conditions: Nasal congestion or runny nose Fever greater than 38 degrees Celsius or chills Headache Muscle pain, extreme tiredness Shortness of breath Cough Nausea, vomiting, abdominal pain Reduced, or lost sense of smell (can you smell peanut butter?) *

Have you had close contact with anyone with respiratory illness or a confirmed or probable/suspected case of COVID-19 in the past 14 days? *

Have you travelled outside of British Columbia in the last 14 days? *

Are you currently the subject of a provincial, territorial or local public health order? *

Name *

First

Last

Email *

Consent *

I confirm that I have answered all the above questions truthfully.