COVID-19 Screening – Eastern Counties Ontario

What is your child's name?(Required)

Fever or chills ?(Required)

Yes
No

Cough?(Required)

Yes
No

Nausea, vomiting, diarhea, abdominal pain?(Required)

Yes
No

Not feeling well, extreme tiredness or sore muscles?(Required)

Yes
No

Difficulty breathing or shortness of breath?(Required)

Yes
No

Sore throat or trouble swallowing?(Required)

Yes
No

Runny nose or nasal congestion?(Required)

Yes
No

Have you travelled outside of Canada within the last 14 days?(Required)

Yes
No

Have you been told to stay home by a health care professional or by the health unit?(Required)

Yes
No

In the last 14 days, have you received a COVID-19 alert exposure notification on your cell phone?(Required)

Yes
No

Is anyone you live with currently experiencing any of the mentioned symptoms and/or waiting for a COVID-19 test result after experencing symptoms?(Required)

Yes
No

Youth Unlimited North Glengarry

Covid-19 screening form