COVID-19 Screening Tool

Name *

First

Last

Did you receive your final (or second) vaccination dose more than 14 days ago? *

No
Yes

A fully immunized individual is defined as any individual >14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID vaccine series (i.e. Johnson and Johnson).

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

No
Yes

Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

No
Yes

Do you have any of the following symptoms?

Fever and/or chills
New onset of cough or worsening chronic cough
Shortness of breath
Decrease or loss of sense of taste or smell
Unexplained fatigue/malaise/muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal pain

Do you have any of the following symptoms? Fever and/or chills New onset of cough or worsening chronic cough Shortness of breath Decrease or loss of sense of taste or smell Unexplained fatigue/malaise/muscle aches (myalgias) Nausea/vomiting, diarrhea, abdominal pain *

No
Yes

Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating? *

No
Yes

COVID Screen Result

Thank you for taking the time to complete these questions. Based on your answers, RMTs cannot provide treatment at this time.

COVID Screen Result

Based on your answers, you do not need to self-isolate or get tested.

Thank you for taking the time to complete these questions.

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