1. Are you experiencing any of the following Symptoms (new or worsening):

Fever - Signs of a fever include chills, sweats, muscle aches and lightheadedness
YesNo

Coughing
YesNo

Sore Throat
YesNo

Painful Swallowing
YesNo

Runny Nose
YesNo

Diarrhea
YesNo

Unexplained Loss of Appetite
YesNo

Loss of Sense of Smell or Taste
YesNo

Small Red or Purple Spots on Hands & Feet
YesNo

2. Have you come in close contact with someone who is confirmed as having COVID-19 in the past 14 days?

YesNo

3. Have you been tested for COVID-19?

YesNo

4. Have you travelled outside of the province in the last 14 days?

YesNo

5. Have you been in close contact with anyone who has travelled outside the province in the last 14 days?

YesNo

Please note that as you enter the facility, you are still required to abide by physical distancing measures as set out by the government of newfoundland and labrador

Full Name

Date

Signature