Name *

First Name

Last Name

Date *

MM

DD

YYYY

Phone *

(###)

###

####

Choose ANY/ALL new, worsening symptoms not related to other known causes or conditions they already have.

Fever AND/OR chills: temperature 37.8°C/100.0°F or higher.

Cough OR Barking Cough: More than usual, making a whistling noise when breathing.

Shortness Of Breath: Out of breath, unable to breathe deeply.

Extreme tiredness: Unusual fatigue, lack of energy.

Muscle Aches OR Joint Pain

Decrease OR Loss Of Taste OR Smell

Sore Throat OR Difficulty Swallowing: *

Painful swallowing, unable to swallow.

Yes

No

Nausea, Vomiting AND/OR Diarrhea: *

Yes

No

Abdominal Pain *

Not related to other known causes or conditions, for example, menstrual cramps, or gastroesophageal reflux disease.

Yes

No

Pink Eye *

Not related to other known causes or conditions, for example, blepharitis, recurrent styes.

Yes

No

Decreased OR No Appetite (YOUNG CHILDREN ONLY) *

Not related to other known causes or conditions, for example, anxiety, constipation.

Yes

No

In The Last (5/10) Days Has The Child Tested Positive For COVID-19: *

This includes a positive COVID-19 test result on a lab-based PCR test, rapid molecular test, rapid antigen test or home-based self-testing kit. Check “No” if you have already completed your isolation period of 5/10 days.

Yes

No

Currently Living In Household With Individual Who Tested Positive For Covid-19: *

The child lives with someone who is currently isolating because of COVID-19 symptoms OR who is isolating while waiting for COVID-19 test results. Select “NO” if your household member is isolating because of COVID-19 symptoms but child has tested negative on one PCR or rapid molecular test or two rapid antigen tests.

Yes

No

In The Last (5, 10) Days Has The Child Been In Close Contact With An Individual Who Has COVID-19 *

The child has come into contact with someone who has COVID-19 or is showing symptoms.

Yes

No

Doctor, Health Care Provider, OR Public Health Unit Told You That The Child Should Be Isolating: *

This can be because of an outbreak or contact tracing.

Yes

No

In The Last 14 Days: *

Has the child travelled outside of Canada and were told to quarantine or has someone in your household.

Yes

No

Please Check Below *

I understand and have answered truthfully all the questions asked above.

I have answered all COVID-19 Screening Questions for Metcalfe Nursery School.