Chedoke-CovidScreening - Starward Homes

First Name(Required)

Last Name(Required)

Company / Trade Name(Required)

How old are you?(Required)

We collect this anonymous information to ask age-specific questions.

17 years old or younger

18 years old or older

Do any of the following apply to you?
- I am fully vaccinated against COVID-19 (it has been 14 days or more since your final dose of either a two-dose or a one-dose vaccine series)
- I have tested positive for COVID-19 in the last 90 days (and since been cleared)

Do any of the following apply to you?(Required)

No

Yes

Are you currently experiencing any of these symptoms?
Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

Are you currently experiencing any of these symptoms?

Fever and/or chills
Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

Cough or barking cough (croup)
Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)

Shortness of breath
Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)

Decrease or loss of taste or smell
Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

Muscle aches/joint pain
Unusual, long-lasting (not related to getting a COVID-19 vaccine in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)

Extreme tiredness
Unusual, fatigue, lack of energy (not related to getting a COVID-19 vaccine in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)

Are you currently experiencing any of these symptoms?

None of the Above

In the last 14 days, have you travelled outside of Canada and been told to quarantine (per the federal quarantine requirements(Required)

No

Yes

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?(Required)

This can be because of an outbreak or contact tracing.

No

Yes

In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit?(Required)

If you have since tested negative on a lab-based PCR test, select "No."

No

Yes

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COVID-19 Screening Form