Health Assessment Health Assessment Questionnaire Name First Last Email PhoneAre you fully vaccinated or confirmed to have the COVID-19 antigen?* I am fully vaccinated against COVID-19 (it has been 14 days or more since your final dose of either a two-dose or a one-dose vaccine series) I have tested positive for COVID-19 in the last 90 days (and since been cleared) None of the Above Are you currently experiencing any of these symptoms? Choose any/all that apply.* Fever (feeling hot to the touch, a temperature of 37.8 degrees Celsius or higher) Chills Cough that's new or worsening (continuous, more than usual) Shortness of breath (out of breath, unable to breathe deeply) Decrease or loss of sense of taste or smell If adult >18 years of age: unexplained fatigue/ / /lethargy malaise muscle aches (myalgias) If child <18 years of age: nausea/vomiting, diarrhea None of the above Have you tested positive for COVID-19 in the past 10 days or have you been told to isolate yourself within the last 10 days?*YESNOHave you travelled outside of Canada in the last 14 days?*YESNOHave you been in close contact with a confirmed case of COVID-19 without wearing appropriate PPE?*YESNO Δ
