COVID-19 Symptoms Checklist Name* First Last Work Email* 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 conditionsFever or Chills*YesNoDifficulty breathing or shortness of breath*YesNoCough*YesNoSore throat, trouble swallowing*YesNoRunny nose/stuffy nose or nasal congestion*YesNoDecrease or loss of smell or taste?*YesNoNausea, vomiting, diarrhea, abdominal pain?*YesNoNot feeling well, extreme tiredness, sore muscles?*YesNoHave you had close contact with a confirmed or probable case of COVID-19?*YesNoHave you travelled outside of Canada in the past 14 days?*YesNoHave you been tested for COVID-19 in the past 14 days?*Yes, the results were negativeYes, the results were positiveYes, I am awaiting the resultsNo, I have not been testedIf you have been tested, what date did you take your test on? Date Format: DD slash MM slash YYYY