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Covid-19 Health Declaration

How are you feeling today?

Name

Phone

Email

COVID-19 Screening

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)

Sore throat Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have

Runny or stuffy/congested nose Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have

Difficulty swallowing Painful swallowing (not related to 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

Pink eye Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)

Headache Unusual, long-lasting (not related to getting a COVID-19 vaccine in the last 48 hours, tension-type headaches, chronic migraines, or other known causes or conditions you already have)

Digestive issues like nausea/vomiting, diarrhea, stomach pain Not related to irritable bowel syndrome, menstrual cramps, 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)

Falling down often For older people

None of the above

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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