COVID-19 Self-Assessment

Your Name (required)

Your Phone Number (10-digit # required)

Your Email (required)

Your Pet's Name (required)

Pet's Date of Birth (required)

Are you currently experiencing any of these symptoms?

Choose any/all that are new, worsening, and not related to a medical condition you already have.

FeverChillsCough that's new or worseningBarking cough, making a whistling noise when breathingShortness of breathSore throatDifficulty swallowingRunny noseStuffy or congested noseDecrease or loss of taste or smellPink eyeHeadache that's unusual or long lastingNausea/vomiting, diarrhea, stomach painMuscle aches that are unusual or long lastingExtreme tiredness that is unusualFalling down oftenSluggishness or lack of appetiteNone of the above

In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?

This includes getting a COVID Alert exposure notification.

YesNo

In the last 14 days, have you been in close physical contact with someone who either:

• is currently sick with a new cough, fever, difficulty breathing, or other symptoms associated with COVID-19? or
• returned from outside of Canada in the last 2 weeks?

Close physical contact means any of the following while not wearing the appropriate personal protective equipment (PPE):

• being less than 2 metres away in the same room, workspace, or area
• living in the same home
• being in the same classroom

YesNo

Have you travelled outside of Canada in the last 14 days?

This does not include essential workers who cross the Canada-US border regularly.

YesNo

Please note: If after sending the form, you do not see a confirmation, please scroll up to see if you missed a required field. (It will be marked with a red "X".

IMPORTANT:

After you have pressed send, please make sure you see a green confirmation box below. If not, please check that you have filled in all required fields.