COVID-19 Questionnaire

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First Name*
Last Name*
Phone*

Please identify if you are experiencing any of the following:
A fever*	Yes Yes No Please Select
Muscle aches or chills*	Yes Yes No Please Select
Shortness of breath*	Yes Yes No Please Select
Difficulty breathing*	Yes Yes No Please Select
Sore throat*	Yes Yes No Please Select
Runny nose*	Yes Yes No Please Select
Have travelled outside Canada within the past 14 day*	Yes Yes No Please Select
Been in contact with anyone that is being*	Yes Yes No Please Select
Monitored or confirmed coronavirus infection*	Yes Yes No Please Select