Mobile Service Health Screening

Mobile Service Health Screening

If you answer YES for yourself or your child to any of the questions, service will not be provided. Please self isolate and call Telehealth or your health care provider, to assess if you need to be screened for COVID-19.

Date

Parent/Guardian:

Tel:

Email:

Child/Participant:

PARENT/GUARDIAN

CHILD/PARTICIPANTS

Do you have any of the following symptoms?

FEVER
NEW ONSET OF COUGH
WORSENING CHRONIC COUGH
SHORTNESS OF BREATH
DIFFICULTY BREATHING
SORE THROAT
DIFFICULTY SWALLOWING
DECREASE OR LOSS OF SENSE OF TASTE OR SMELL
CHILLS
HEADACHES
RUNNY NOSE
NASAL CONGESTION WITHOUT KNOWN CAUSE
UNEXPLAINED FATIGUE/MUSCLE ACHES
NAUSEA/VOMITING, DIARRHEA, ABDONMINAL PAIN

PARENT/GUARDIAN

YesNo

CHILD/PARTICIPANTS

YesNo

Have you travelled outside of Canada in the past 14 days?

PARENT/GUARDIAN

YesNo

CHILD/PARTICIPANTS

YesNo

Have you had close contact with a someone who is sick or has confirmed COVID-19 in the past 14 days?