Covid Weekly Screening : Fort McMurray SDA Church Fort McMurray AB

Phone

Email

Today’s Date and Activity Start Time:

Do you have a Fever (greater than 38.0C)

Yes No

Cough

Yes No

Shortness of Breath/Difficulty Breathing

Yes No

Sore Throat

Yes No

Chills

Yes No

Painful swallowing

Yes No

Runny Nose/Nasal Congestion

Yes No

Feeling unwell/Fatigued

Yes No

Nausea/ Vomiting/ Diarrhea

Yes No

Unexplained loss of appetite

Yes No

Loss of sense of taste or smell

Yes No

Muscle / Joint aches

Yes No

Headache

Yes No

Conjunctivitis

Yes No

2. Have you, or anyone in your household travelled outside of Canada in the last 14 days?

Yes No

3. Have you or your children attending the program had close unprotected contact (face-to-face contact within two-meters) with someone who is ill with cough and/or fever?

Yes No

4. Have you or anyone in household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?

Yes No

1: Do you have any of the below symptoms?