COVID-19 Screening Form

Name

Email address

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 conditions. 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 conditions. Fever or Chills Difficulty Breathing or Shortness of Breath Cough Sore throat or trouble swallowing Runny nose/stuffy nose or nasal congestion Decrease or loss of smell or taste Nausea, vomiting, diarrhea, abdominal pain Not feeling well, extreme tiredness, sore muscles None of the above

Have you travelled outside of the Kingston area in the past 14 days? Have you travelled outside of the Kingston area in the past 14 days? Yes No

If Yes, Where did you travel to?

Have you had close contact with a confirmed or probable case of COVID-19? Have you had close contact with a confirmed or probable case of COVID-19? Yes No