Covid19 RMT Assessment

Name *

First

Last

Are you experiencing any of the following:

Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)
Severe chest pain
Having a very hard time waking up
Feeling confused
Losing consciousness

1st Question *

Are you experiencing any of the following:

Mild to moderate shortness of breath
Inability to lie down because of difficulty breathingn
Chronic health conditions that you are having difficulty managing because of difficulty breathing

2nd Question *

Are you experiencing any of the following:

Fever
Cough
Sore throat
Runny nose
Headache

3rd Question *

Did you develop symptoms within 14 days of travel outside Canada? Travel includes passing through an airport outside Canada.

4th Question *

Did you provide care or have close contact with a person with COVID-19 (probable or confirmed) while they were ill (fever, cough, sore throat, runny nose or headache)?

A close contact is defined as a person who:

Provided care for the individual, including healthcare workers, family members or other caregivers, or who had other similar close physical contact without consistent and appropriate use of personal protective equipment; or
Lived with or otherwise had close prolonged contact (within 2 metres) with the person while they were infectious; or
Had direct contact with infectious bodily fluids of the person (e.g. was coughed or sneezed on) while not wearing recommended personal protective equipment.

5th Question *

Did you have close contact with a person who travelled outside of Canada in the last 14 days who has become ill (fever, cough, sore throat, runny nose or headache)?

A close contact is defined as a person who:

Provided care for the individual, including healthcare workers, family members or other caregivers, or who had other similar close physical contact without consistent and appropriate use of personal protective equipment; or
Lived with or otherwise had close prolonged contact (within 2 metres) with the person while they were infectious; or
Had direct contact with infectious bodily fluids of the person (e.g. was coughed or sneezed on) while not wearing recommended personal protective equipment.

6th Question *

I’m not feeling well. What should I do next?

The Public Health Agency of Canada strongly urges anyone who has any of the following symptoms: fever, cough, sore throat, runny nose, or headache to ISOLATE at home or another suitable location.

For more information on COVID-19, refer to the Government of Canada COVID-19 website