COVID-19 Screening Survey
If you answered YES to any of these questions,
go home & self-isolate right away. Call Telehealth
or your health care provider, to find out if you
need a test.

**COMPLETE FOR EACH CHILD**
Email address *
Child's Name: *
Today's Date *
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1. Does your child have any of the following NEW or WORSENING symptoms? symptoms should not be chronic or related to other known causes or conditions.
Fever and/or chills ( temperature of 37.8 C/ 100.0 F or greater) *
Cough ( more than usual if chronic cough) including croup (barking cough, making a whistling noise when breathing) Not related to other known causes or conditions (e.g., asthma, reactive airway) *
Shortness of breath (dyspnea, out of breath, unable to breathe deeply, wheeze, that is worse than usual if chronically short of breath) NOT RELATED TO OTHER KNOWN CAUSES (e.g., asthma) *
2. Does your child have any of the following new or worsening symptoms? symptoms should not be chronic or related to other known causes or conditions.
Sore throat (painful swallowing or difficulty breathing) Not related to other known causes or conditions (e.g., post drip, gastroesophageal reflux) *
Stuffy nose and/or runny nose ( nasal congestion and/or rhinorrhea) Not related to other known causes or conditions (e.g., seasonal allergies, returning inside from the cold, chronic sinusitis unchanged from baseline, reactive airways) *
Headache that is new and persistent, unusual, unexplained, or long-lasting. Not related to other known causes or conditions *
Nausea, vomiting and/or diarrhea Not related to other known causes or conditions (e.g. transient vomiting due to anxiety in children, chronic vestibular dysfunction, irritable bowel syndrome, inflammatory bowel disease, side effect of medication) *
Fatigue, lethargy, muscle aches or malaise ( general feeling of being unwell, lack of energy, extreme tiredness, poor feeding in infants) that is unusual or unexplained. Not related to other known causes or conditions (e.g., depression, insomnia, thyroid dysfunction, anemia) *
3. Has your child travelled outside of Canada in the past 14 days? *
4. Has your child been identified as a close contact of someone who is confirmed as having COVID-19 by your local public health unit (or from the COVID-19 Alert app if they have their own phone) *
5. Has your child been directed by a health care provider including public health officials to isolate? *
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