Screening Form - Relative Space

Name*

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.

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*

Have you travelled outside of Canada in the past 14 days?*

Have you had close contact with a confirmed or probable case of COVID-19?*