Name

Email Address

Phone

Are you experiencing any of the following: Are you experiencing any of the following: 1. Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)2. Severe chest pain3. Having a very hard time waking up4. Feeling confused5. Losing consciousness6. Mild to moderate shortness of breath7. Inability to lie down because of difficulty breathing8. Chronic health conditions that you are having difficulty managing because of difficulty breathingYesNo

Check off all of the symptoms you are experiencing right now

Select the symptoms you have. If you are not experiencing any symptoms, select "None of the above." Select the symptoms you have. If you are not experiencing any symptoms, select "None of the above." Fever or chills Cough Difficulty breathing Sore throat Loss of sense of smell or taste Headache Extreme fatigue or tiredness Extreme fatigue or tiredness Diarrhea Loss of appetite Nausea or vomiting Body aches None of the above

Have you returned to Canada from any country (Including the United States) within the last 14 days? Have you returned to Canada from any country (Including the United States) within the last 14 days?YesNo

Did you have close contact with a person with confirmed COVID-19 within the last 14-days? (close contact is defined as being near a known person with COVID-19 for at least 15-mins) Did you have close contact with a person with confirmed COVID-19 within the last 14-days? (close contact is defined as being near a known person with COVID-19 for at least 15-mins)YesNo