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COVID-19 Assessment Form
1. Are you currently experiencing any of the following symptoms? • new or worsening cough • shortness of breath or difficulty breathing • temperature equal to or more than 38°C • feeling feverish • chills • fatigue or weakness • muscle or body aches • new loss of smell or taste • headache • abdominal pain, diarrhea and vomiting • feeling very unwell
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2. Have you been in close contact with anyone who is currently experiencing the symptoms listed above?
Yes
No
3. Have you returned from travel outside of Canada in the past 14 days?
Yes
No
4. Have you been in close contact with anyone who is returning to Canada in the past 14 days?
Yes
No
5. Have you or anyone you have been in contact with been diagnosed with COVID-19?
Yes
No
6. Are you under current instruction or were previously (within 14 days) instructed by a public health unit to self-isolate?
Yes
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