Covid Self Assessment Form | McCowan and Associates

Name: *

Email: *

Phone Number: *

Date: *

Time: *

1) Do you have any of the following new or worsening symptoms or signs?  Symptoms should not be chronic or related to other know causes or conditions.:

Fever or Chills

Yes No

Difficulty breathing or shortness of breath

Yes No

Cough

Yes No

Sore throat/trouble swallowing

Yes No

Runny nose/stuffy nose or nasal congestion

Yes No

Decrease or loss of smell or taste

Yes No

Nausea, vomiting, diarrhea, abdominal pain

Yes No

Not feeling well, extreme tiredness, sore muscles

Yes No

Pink eye

Yes No

Headache

Yes No

Falling down

Yes No

2) In the past 14 days, have you or anyone you live with travelled outside of Canada?

Yes No

3) Have you had close contact with a confirmed or probable case of COVID – 19?

Yes No

4) Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

Yes No

5) In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?

Yes No

6) Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

Yes No