Covid Screen Posted on 13-0613-06 by IMSC As part of our preliminary screening for COVID-19, we have a few questions we will need you to answer: Name*FirstLast Phone* Email Have you had a COVID test done before?*YesNoDate of Test (enter no if no test)PositiveNegative In the last 14 days, have you:(1)*Returned from travel outside of Canada?Been in close contact with anyone diagnosed with lab confirmed COVID-19?Lived or worked in a setting that is part of a COVID-19 outbreak?Been advised to self-isolate or quarantine at home by public health?NONE OF THE ABOVE Do you have new onset of any of the following symptoms:*FeverCough: new or worse than usualShortness of breathDiarrheaNausea and/or vomitngHeadacheRunny nose/nasal congestionSore throat or painful swallowingLoss of sense of smellLoss of appetiteChillsMuscle achesFatgueNONE OF THE ABOVE Word VerificationSubmitReset
