COVID-19 Field Form

*Do you currently have one or more of the COVID-19 symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions Fever and/or chills, cough or barking cough (croup), shortness of breath, sore throat, difficulty swallowing, decrease or loss of smell or taste, runny or stuffy/congested nose, headache, nausea/vomiting, diarrhea, muscle aches/joint pain, fatigue, pink eye (for adults), stomach pain (for adults), falling down often (for older adults). If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”

Yes

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing *Fever and/or chills, cough or barking cough (croup), shortness of breath, sore throat, difficulty swallowing, decrease or loss of smell or taste, runny or stuffy/congested nose, headache, nausea/vomiting, diarrhea, muscle aches/joint pain, fatigue, pink eye (for adults), stomach pain (for adults), falling down often (for older adults). If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”

Yes

Do you live with someone who has been told by a doctor, health care provider, or public health unit that they should currently be isolating? If you are fully vaccinated** , select “No.” *If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”

Yes

If you answer YES to any one of the questions above, PLEASE DO NOT enter this location AND contact either your health care provider or Telehealth Ontario (1-866-797-0000) to get advice or an assessment, including if you need a COVID-19 test.

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