Covid Screening – Watari.ca

Name and Last Name*

Date*

Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions:*

Severe chest pain, Having a very hard time waking up, Feeling confused, Losing consciousness, Fever or chills, Difficulty breathing or shortness of breath, Cough, Sore throat, trouble swallowing, Runny nose/stuffy nose or nasal congestion, Decrease or loss of smell or taste, Nausea, vomiting, diarrhea, abdominal pain, Not feeling well, extreme tiredness, sore muscles.

Yes
No

2. Have you travelled outside of Canada (including the US) in the past 14 days?*

Yes
No

3. Have you had close contact with or provided care for a person with confirmed COVID-19?*

Yes
No

In the last 14 days have you been in close contact with someone who returned from outside of Canada in the last 2 weeks with new COVID-19 symptoms (like a cough, fever, or difficulty breathing)?*

Yes
No

Have you been in close contact with someone with new COVID-19 symptoms (like a cough, fever, or difficulty breathing) in the last 14 days?*

Yes
No