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COVID-19 Form

Are you experiencing any of the following symptom: *
- Severe Difficulty Breathing (eg: struggling to breath or speaking in single words)
- Severe chest pain
- Having a very hard time waking up
- Feeling confused
- Losing consciousness
Are you experiencing any of the following symptom: *
- Mild to moderate shortness of breath
- Inability to lie down because of difficulty breathing
- Chronic health conditions that you are having difficulty managing because of difficulty breathing
Did you provide care or have close contact with a person confirmed with COVID-19? *
Note: This means you would have been contacted by your health authority's public health team
Are you experiencing cold, flu or COVID-19-like symptoms, even mild ones? *
Symptoms include: fever*, chills, cough or worsening of chronic cough, shortness of breath, sore throat, runny nose, loss of sense of smell or taste, headache, fatigue, diarrhea, loss of appetite, nausea and vomiting, muscle aches.

While less common, symptoms can also include stuffy nose, conjunctivitis (pink eye), dizziness, confusion, abdominal pain, skin rashes or discolouration of fingers or toes.

**Fever: Average body temperature taken orally is about 37º Celsius.
Have you travelled to any country outside Canada (including the United States) within the last 14 days? *
Do you work for Custom Realty or Foreman Auto?


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