Are you experiencing any of the following *

• severe difficulty breathing (e.g., struggling for each breath, speaking in single words)
• severe chest pain
• having a very hard time waking up
• feeling confused
• lost consciousness
• Unable to lie down due to shortness of breath

Do you have two or more of the following symptoms (new or worsening) *

• Fever (or signs of a fever such as chills, sweats, muscle aches and lightheadedness)
• cough
• headache
• sore throat
• painful swallowing
• runny nose
• unexplained loss of appetite
• diarrhea
• loss of sense of smell or taste

• are you experiencing small red or purple spots on your hands and/or feet?

In the past 14 days have you had close contact with someone who is confirmed as having COVID-19? *

A close contact is defined as a person who:

• provided care for the individual, including healthcare workers, family members or other caregivers, or who had other similar close physical contact without consistent and appropriate use of personal protective equipment OR
• who lived with or otherwise had close prolonged contact (within 2 meters) with the person while they were infectious OR
• had direct contact with infectious bodily fluids of the person (e.g. was coughed or sneezed on) while not wearing recommended personal protective equipment

In the past 14 days have you returned from travel outside the Province? *

Travel includes passing through an airport.