Covid-19 Screening Form (DHB Graphics & Sign)
First and Last Name
Q1. Did you receive second COVID-19 vaccination dose more than 14 days ago?
Q2. Do you have any of the following symptoms?
Fever and/or chills
New onset of cough or worsening chronic cough
Decrease or loss of sense of taste or smell
If adult over 18 years of age: unexplained fatigue/ lethargy/ malaise/ muscle aches (myalgias)
If child 18 and under: Nausea/ vomiting, diarrhea
None of the above
Q3. Have you been tested positive for COVID-19 in the past 10 days or have you been told to be self isolating?
Q4. Did you travel outside of Canada in the past 14 days?
Q5. Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?