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Covid-19 Health Declaration
How are you feeling today?
First Name
Last Name
Email
Have you experienced any of the following symptoms?
Fever or Chills
Cough
Sore Throat
Difficulty Breathing
Nausea and/or Vomiting
Body Aches
Loss of Appetite
Headache
Loss of sense of smell or taste
Diarrhea
None of the above
2. Have you traveled outside Canada, including the United States, within the last 14 days?
*
Yes
No
3. Did you provide care or have close contact with a person with COVID-19 (probable or confirmed) while they were ill (cough, fever, sneezing, or sore throat) within the last 14 days?
*
Yes
No
4. Did you have close contact with a person who travelled outside of Canada in the last 14 days who has become ill (cough, fever, sneezing, or sore throat)?
*
Yes
No
5. Have you or anybody in your home had contact with someone who is being tested for COVID-19 or who has been diagnosed with COVID-19.
*
Yes
No
Initials
Date
I declare that the info I’ve provided is accurate & complete
Submit
Thanks for submitting!
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