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COVID-19 Screening Tool
Name
Do you have any of the following:
1. Fever / Chills
Yes
No
2. New cough or cough that is getting worse
Yes
No
3. Difficulty breathing
Yes
No
4. Shortness of breath (even when sitting or walking regularly)
Yes
No
5. Sore throat (not due to allergies)
Yes
No
6. A runny or congested nose (not due to allergies)
Yes
No
7. Unusual level of fatigue
Yes
No
8. Unusual headache
Yes
No
9. Nausea / vomitting, diarrhea,or loss of apettite
Yes
No
10. Feeling unwell for an unknown reason
Yes
No
Have you been in close contact with someone who is either sick , sent for testing, or has confirmed COVID-19 in the past 14 days?
Yes
No
Have you returned from travel outside Canada in the past 14 days?
Yes
No
Recorded Temperature
If you answered YES to any of these questions, notify your workplace, go home and self-isolate right away.
Call your health care provider or HPPH Health Line at 1-888-221-2133 ext 3267 and a public health nurse will give you detailed instructions to follow to protect you, your family, and members of the public.
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